Key principles for effective QI interventions

Key principles for effective QI interventions

The VTE protocol sounds simple, doesn’t it? It is, but as always, the devil is 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.
There will inevitably be trade-offs between the depth of detail you want to give providers and the simplicity of the forms and the processes the end users have to go through. 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 for each VTE risk category.

Principle # 2. You can’t interrupt the 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 your plans are feasible, and that your protocol is easy to use. Without their input implementation will not go smoothly. Quick focus group feedback is invaluable. Don’t expect the end users to go out of their way to download or locate a VTE risk assessment form. If you cannot nest a VTE risk assessment into an admission/transfer order set, a stand-alone VTE risk assessment sheet had better be stapled to the admission packet – and the admission packet must be easy to find wherever it is needed and it must be re-stocked regularly. Check boxes and pre-written scales can encourage rapid acceptance because they make the work easier. Clinicians should want to use your order sets if they are constructed properly. In general, if your intervention interrupts workflow it will be rejected.

Principle # 3. Design reliability into the process.
Human beings are incapable of doing anything reliably 100% of the time in the complicated health care setting. Part of your team’s job is to engineer higher reliability into the process of protecting patients from hospital-acquired VTE. If your VTE risk assessment protocol relies solely on the following traditional methods you will be disappointed with the results:

• Common equipment and order sets
• Personal check lists
• Working harder next time
• Feedback of information on compliance
• Awareness and training

All of the above methods are helpful (and some are necessary), but they are not sufficient to achieve breakthrough improvement.  You must design interventions that use at least one of the following strategies if you aim for reliable prevalence of VTE prophylaxis.

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 the admission 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 admission order set that has no prophylaxis selected, the responsibility for ensuring VTE prophylaxis is made redundant. If a member of the care team performs regular review of patient medication administration records, responsibility for re-assessment for changing VTE risk or failure to resume held pharmacoprophylaxis can be scheduled and also made redundant. All of the above strategies would increase the reliability that patients are on appropriate VTE prophylaxis at any moment. 

Principle 4. Pilot your interventions on a small scale before attempting wide implementation.
No plan survives its first contact with reality. Inevitably there will be glitches with your first pass at anything new. So why not learn faster by failing faster? By piloting on a small scale you afford yourself an opportunity to iron out the glitches before you implement more broadly. Small-scale pilots can be as simple as a 5-minute focus group where 5 physicians give feedback on several versions of your 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 your protocol.
Rolling out the protocol is really only a beginning. You must have a plan that ensures the VTE protocol is part of the completed admission orders for every patient who enters your medical center.

You will need to learn from variations that arise from logistics, patients, providers, and other variables.  You should expect variations from the protocol, but ‘capture’ those instances, learn from them, and react by taking steps to reduce them. Why isn’t the order set being 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 service needs our 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.

It is quite important, however, to preserve the freedom of provider’s to vary from the protocol. There will always be a need for providers to tailor care to meet the needs of special patients, or to accommodate special circumstances.