Layering Interventions
Beyond the VTE Protocol: Using a “Hierarchy of Reliability”
Consider the following “hierarchy of reliability” when planning and executing the VTE prevention initiative. By using this guide and a little ingenuity, a serious institutional effort should be able to achieve the impressive performance gains of Level 4. Successful Level 5 reliability, as we have demonstrated in pilots at our institutions, is within reach of many institutions with electronic medication administration records.
Level 1: State of Nature
In the “unimproved” modern hospital patients receive care that depends solely on the knowledge, skills, and memory of their physicians. There is no standardized assessment for VTE risk and there are no reminders within the real-time flow of care delivery to prompt physicians to order VTE prophylaxis. In this “state of nature,” expect approximately 40% of patients to be on appropriate VTE prophylaxis at any given moment.
Level 2: Average
Many hospitals that have tried to improve VTE prophylaxis find themselves at Level 2, with only partially effective components of a VTE protocol:
- A standardized VTE risk assessment to guide choice of VTE prophylaxis, but it is not well integrated into admission and transfer order sets (e.g. the VTE protocol exists only as a stand–alone form or pocket card), or
- A prompt to order VTE prophylaxis is nested within admission and transfer order sets, but no VTE risk assessment exists to guide choice of VTE prophylaxis
Level 3: VTE Protocol
Level 3 is the entry point for most serious QI efforts – a complete VTE protocol. All 3 elements of a complete VTE protocol are combined within a paper order set or CPOE. The more effective VTE protocols also have a visual link from the level of VTE risk to the options for appropriate prophylaxis; this visual link enables providers to make a rapid, accurate decision and action to order appropriate prophylaxis.
In a Level 3 VTE prevention program not only are providers prompted to order VTE prophylaxis when completing admission or transfer orders, they also have a standardized VTE risk assessment immediately available to support medical decision-making. Level 3 makes it possible for providers to have what they need, when and where they need it, to make an appropriate prophylaxis choice. Expect 65-85% of patients to be on appropriate VTE prophylaxis with the Level 3 VTE protocol.
Remember that providers should always retain the freedom to deviate from the protocol when meeting the needs of a given patient. The protocol, with successive refinements, eventually should drive management choices in the great majority of patients.
Level 4: Layers of QI Strategies that Leverage the VTE Protocol
All of the conditions of Level 3 exist, but the use of the VTE protocol at admission and transfer is enhanced by additional QI strategies. Level 4 uses high reliability mechanisms to make it a rare event for a patient to enter the hospital without going through your VTE protocol.
Also at Level 4, any variations from the protocol or adverse effects while on the protocol are studied in depth. The protocol and its integration are continually refined and its use continually increased based on these events, using the collective intelligence, experience, and investigation of the institution.
Use the table “Armamentarium of QI Strategies” as a source of additional Level 4 ideas. Most of these other strategies leverage the existence of a VTE protocol well-integrated in the workflow. Providers, nurses, pharmacists, even patients can refer back to the VTE protocol for clarity, confidence, or advocacy. Remember, any additional, layered interventions should include at least one high reliability mechanism in the design. Expect 80-90% of patients to be on appropriate VTE prophylaxis with Level 4, an extremely impressive level of performance that would place the medical center among better performers.
Level 5: Oversights “Identified-and-Mitigated”29
Level 5 represents a profound leap in quality. Here the team improves care by a whole order of magnitude, a rare achievement in health care. All of the conditions of Level 4 exist, plus there is now a strategy to identify and address the prophylaxis oversights that inevitably occur. Back at Level 4, at least one in 10 patients still fail to receive appropriate prophylaxis. Will the team be satisfied with that considerable gain? It depends on whether the team is merely pursuing excellence (relative to “industry standards”), or actually pursuing perfection. Instances will always occur where VTE prophylaxis is not ordered on admission or transfer, or not replaced with alternatives when contraindications arise, or not resumed when suspected contraindications fail to materialize, or not administered properly when ordered (i.e. mechanical prophylaxis). Strategies that “identify-and-mitigate” these oversights are critical for sustaining prophylaxis prevalence over 90%. Level 5 may be impractical or unsustainable without an electronic medication record and reporting mechanism.
A mature Level 5 will also judge the efficacy of mitigation itself and its own failures will be immediately remedied. Failure modes of mitigation would be systematically catalogued, analyzed, and then eliminated. Achieving this level of reliability across an entire hospital would represent a pioneering effort in VTE prevention. Level 5 solutions transferable to other institutions would represent something transformative for hospital care.
Armamentarium of QI Strategies
QI Strategy Categories Specific Ideas for VTE Prevention
Provider education |
• Didactic sessions on VTE prevention (e.g. noon conference, grand rounds, etc)
• Distributed educational materials (e.g. pocket cards with VTE risk factors, etc) |
Provider reminder systems |
• Prompts nested within paper admission/transfer/post-op order sets supported by VTE risk assessment as decision support (VTE protocol)
• Prompts using CPOE with risk assessment as decision support (VTE protocol)
• Stickers on charts or posters in order-writing areas |
Facilitated relay of clinical data to providers |
• Alerts to physicians by means other than medical record, e.g., page, electronic alert, phone call, email to provider regarding VTE prophylaxis oversights. |
Audit and feedback of performance to providers |
• Feedback of VTE prophylaxis performance to individual providers or groups of providers (with or without benchmarking to top performers) |
Patient education |
• Discrete disclosure to patients of increased risk for VTE (e.g. pamphlets, physician or nurse teaching of patient or caregiver, closed circuit TV program in patient rooms, etc.) |
Organizational or operational change |
• Administrative support personnel dedicated to ensure constant stocking of VTE protocol order set in needed areas
• Clinical support personnel dedicated to ensure and document that mechanical prophylaxis is worn by patients
• Hospital-wide (or unit-specific) teams or individuals with regular responsibility to ensure each patient is receiving appropriate VTE prophylaxis (e.g. physician, nurse, pharmacist, etc), a.k.a. “VTE Hit Squad” |
Incentives, regulation, and policy |
Provider-Directed:
• Honor recognition of highest performers each month or quarter
• Financial incentives based on achievement of VTE prophylaxis performance goals
• Punitive actions for failures to meet minimum performance (suspension of privileges, stockade in town square, etc.)
Health System-Directed:
• Enforced policy mandating use of VTE protocol (e.g. “hard stops” in processing of admission/transfer/post-op orders that fail to prescribe VTE prophylaxis) |
Source adapted from Stein J. The Language of Quality Improvement: Therapy Classes. J Hosp Med. 2006 Nov;1(6):327-30.
§ Nolan T, Resar R, Haraaden C, Griffin F. White Paper: Improving the Reliability of Health Care. Institute for Healthcare Improvement. Innovation Series 2004. http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm
Accessed December 1, 2006.
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