Key principles for effective QI interventions
Key principles for effective QI interventions
The VTE protocol sounds simple, but the devil can be in the details. A protocol, and any subsequent layers of QI interventions, will usually fail unless the team pays attention to these details. A review of some principles for effective interventions is in order:
Principle #1. Keep it simple for the end user.
Inevitably there will be trade-offs between the depth of detail to give providers and the simplicity of the forms and processes they are asked to accept. Almost always, simpler is better. Minimize calculations the end user has to make, or automate that process for them. Limit prophylaxis options to as few as possible for each VTE risk category.
Principle #2. Do not interrupt workflow.
It is safe to assume the care-giving team will have multiple demands competing for attention and time. Involve frontline workers to make sure the VTE protocol is easy to use. Without input from the front-line, implementation will not go smoothly. Focus- group feedback is invaluable and easy to do. Check-box orders are much easier to use than free text and can encourage acceptance of a new form. If the team cannot nest a VTE risk assessment within admission, post-operative, or transfer order sets, a stand-alone VTE risk assessment sheet should be stapled to the order set – and the order set must be easy to find wherever and whenever it is needed. End users are unlikely to go out of their way to download or locate a VTE risk assessment form. It must be re-stocked regularly. Clinicians should want to use your order sets if you design them properly. In general, if your VTE protocol interrupts workflow it will be rejected.
Principle #3. Design reliability into the process.
Especially in the complicated health care setting, do not expect humans to be perfect. Part of the team’s job is to engineer higher reliability into the process of protecting patients from hospital-acquired VTE. If the VTE protocol relies solely on the following traditional methods, the team will be disappointed with the results:
- Order sets
- Personal check lists
- Working harder next time
- Feedback of performance
- Awareness and training
All of the above methods are helpful and some are even necessary, but they are not sufficient alone to achieve breakthrough improvement. The team must design interventions that use at least one of the following high reliability strategies.
High Reliability Strategies
If designed well, the VTE protocol will be an intervention that invokes several of these high reliability strategies. If it is nested into existing order sets it can serve as a reminder to prompt ordering of prophylaxis. If admission, post-op, or transfer order sets are themselves easy to use, always stocked, and easy to find where providers need them, the VTE protocol can be standardized into the process of writing most admission orders. If a clerk or pharmacist is empowered to halt processing of an order set that has no prophylaxis selected, the responsibility for ensuring VTE prophylaxis can be made redundant. If a member of the care team performs regular review of patient medication administration records, responsibility for finding prophylaxis “outliers” can be scheduled and also made redundant. All of the above strategies would increase the reliability that patients receive VTE prophylaxis appropriately.
Principle #4. Pilot interventions on a small scale before attempting wider implementation.
No plan survives its first contact with reality. Inevitably there will be glitches with a first pass at anything new. So why not learn faster by failing faster? Piloting on a small scale creates opportunities to iron out glitches before implementing more broadly. Small-scale pilots can be as simple as a 5-minute focus group where 5 physicians give feedback on several versions of the protocol. The next pilot could consist of trying out the protocol on one patient with one physician and one nurse.
Principle #5. Monitor use of the protocol.
Rolling out the protocol is really only a beginning. The team must have a plan that ensures the VTE protocol is part of the completed admission orders for every patient who enters the medical center.
When providers do not use the protocol or deviate from it, reasons might derive from logistics, patients, providers, and other variables. The team should anticipate variations from the protocol, but should capture those instances, learn from them, and react by taking steps to reduce them. Why is the order set not used in some areas? Can we integrate it into other heavily used order sets? Which types of admissions are inadvertently bypassing our protocol? Which patients just don’t fit with our protocol - can we change it so that it fits more patients and situations? Which providers would benefit from focused educational efforts? Are we stocking and re-stocking the protocol in all the key areas in the hospital? While no protocol will fit every patient, the idea is to squeeze needless variability out of medical decision-making and ordering.
Remember, though, it is quite important to preserve the freedom of provider’s to vary from the protocol due to medical necessity. There will always be a need for providers to tailor care to meet the needs of individual patients, or to accommodate special circumstances.
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