1-30 CSE final 2
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This document outlines a quality improvement project at Texas Health Presbyterian Dallas hospital to increase compliance with Surgical Care Improvement Project (SCIP) venous thromboembolism (VTE) prophylaxis measures. The project team aims to achieve top decile compliance by December 2012. Opportunities for improvement were identified through audits showing missed opportunities by unit and surgery type. Changes implemented include education, checklists, order sets and meetings. Monitoring shows checklist compliance increasing from less than 10% to over 90%. Ongoing efforts include physician and nurse education and concurrent review to sustain gains.
1-30 CSE final 2
- 1. 1 TEXAS HEALTH PRESBYTERIAN DALLAS06/01/15 1 TEXAS HEALTH PRESBYTERIAN DALLAS SCIP Venous Thromboembolism Prophylaxis Jennifer Caldwell, RN Kathy Moon, BSN, RN February 8, 2012 1
- 2. 2 TEXAS HEALTH PRESBYTERIAN DALLAS AIM STATEMENT 2 The project aims to increase Inpatient SCIP VTE prophylaxis compliance to top decile by December 31, 2012.
- 3. 3 TEXAS HEALTH PRESBYTERIAN DALLAS Team Members – Jen Caldwell, RN- CS&E Participant – Kathy Moon, BSN, RN- CS&E Participant – Dr. Hagood- Physician leader – Jen Rainer-Facility Facilitator – Eleanor Phelps- CS&E Facilitator – Team Members: Dr. Appel- physician Keith Turner-IT physician liaison Jen Mosley-nursing Andrew Faust- pharmacy Susan Cooper-nursing Phyllis McCortsin- APN nursing Michelle Phillips- nursing Annette Cox- nurse education 3
- 4. 4 TEXAS HEALTH PRESBYTERIAN DALLAS Measure of Success • Achieve and sustain top decile SCIP VTE prophylaxis compliance by December 31, 2012 • Top Decile 100% VTE-1 and 99.84% VTE-2 • Currently VTE-1, VTE-2 compliance trending upward • Preliminary Q4, VTE-1 and VTE-2 99.5% 4
- 5. 5 TEXAS HEALTH PRESBYTERIAN DALLAS 5 PDSA
- 6. 6 TEXAS HEALTH PRESBYTERIAN DALLAS PLAN • PI Team co-chaired by Jen Caldwell and Kathy Moon • Develop charter for project team • Nursing representation from nursing units, Care Connect team and Quality • Brainstorming • Ishikawa Diagram • Focus improvements on VTE prophylaxis administration compliance 6
- 7. 7 TEXAS HEALTH PRESBYTERIAN DALLAS 7 Unable to make VTE Core Measure Metric Management Culture of approaching MDs Clinical leaders not comfortable performing audits Man Measurement Machine Material Method MDs not wanting to be told what to do Lack of education Lack of MD buy in No policy requiring VTE assessment Distribution of SCDS Only able to do sample auditing SCDs not available No SCIP list available Manually enter SCIP core measures Icon daily Redundancy of BPA alerts MDs do not know appropriate documentation Lack of documentation Knowledge of SCIP BPA Alerts fatigue No SCD order set or protocol OR schedule not linked to order sets RNs do not use SCIP checklist Ease of use Phases of release of orders (PACU) BPA goes off with SCDs even if Pharm VTE needed MDs don't know how to use VTE calculator No problem list, order set, or hard stop Caprini Ref Tool not used Pharmacy does not review for appropriateness Lack Education Support
- 8. 8 TEXAS HEALTH PRESBYTERIAN DALLAS DO • Used fishbone to identify problems barriers and develop actions • Drill down—opportunities on M6E, M6W • Conduct concurrent review of SCIP charts • Conduct literature review to identify evidence based practice for improvement opportunities • Implement daily alert sheet for nursing units • Nurses reported inconsistent use of SCIP checklist - created SCIP checklist TIP sheet • Implement utilization of sticky notes in Care Connect • Attend nursing staff meetings • Attend MD department meetings • Implement CARE -Concurrent Accountability Review and Education meetings • Review of charts indicated less than 10% compliance of checklist • Review of order sets • Create pocket guides 8
- 9. 9 TEXAS HEALTH PRESBYTERIAN DALLAS Missed Opportunities by Unit 9
- 10. 10 TEXAS HEALTH PRESBYTERIAN DALLAS Missed Opportunities by Surgery Type 10
- 11. 11 TEXAS HEALTH PRESBYTERIAN DALLAS Missed Opportunities by Surgeon 11
- 12. 12 TEXAS HEALTH PRESBYTERIAN DALLAS SCIP Checklist Tip Sheet 12 The SCIP checklist is filled out on all surgical patients. It should be started on admission by the nurse caring for the patient at that time. Ideally, anytime SCIP criteria are carried out, the nurse should go to the checklist and document. It will become easier to do as you are familiar with the criteria. Do not leave the checklist for the discharge nurse to complete. These step-by step instructions will hopefully make completing the checklist a little easier. Each nurse caring for patient should ensure checklist is completed on their shift. In addition, include the checklist during transfer of care. The checklist box will open, click on the SCIP box (it is on the far right, you might need to scroll over) To open SCIP checklist click on checklist (IF you do not have the checklist tab, please see superuser or EPIC educator).
- 13. 13 TEXAS HEALTH PRESBYTERIAN DALLAS Gantt 13
- 14. 14 TEXAS HEALTH PRESBYTERIAN DALLAS STUDY • Continue with concurrent review • Continue to monitor use of SCIP checklist • Monitoring VTE core measure scores • Feed back from physicians/nursing regarding process 14
- 15. 15 TEXAS HEALTH PRESBYTERIAN DALLAS ACT • Continue education and data collection • Monitor compliance of SCIP checklist usage with reports • Continue open communication with staff to further identify opportunities to hardwire the VTE prophylaxis process • Review new care connect standard order sets after 2013 changes 15
- 16. 16 TEXAS HEALTH PRESBYTERIAN DALLAS Checklist Compliance Results 16
- 17. 17 TEXAS HEALTH PRESBYTERIAN DALLAS 17
- 18. 18 TEXAS HEALTH PRESBYTERIAN DALLAS NEXT STEPS Ongoing- • MD Education—handouts for MD’s, new physician orientation • Nursing Education—SCIP purpose, checklist, VBP, Nurse unit meetings, CARE Meetings, new nurse orientation • Continue Concurrent Review • Daily Alerts/Sticky Notes • Monitor of Core Measure dashboard 18
- 19. 19 TEXAS HEALTH PRESBYTERIAN DALLAS Project Challenges • Changes to Care Connect slow- system wide • Physician culture • Resistance to hard stops in EMR • Outreach difficult r/t multiple surgical groups • Owner of SCIP checklist 19
- 20. 20 TEXAS HEALTH PRESBYTERIAN DALLAS Lessons Learned • Ensure right people at the table • System approach hard to get changes in timely manner • Physicians more receptive one on one (more time consuming)
- 21. 21 TEXAS HEALTH PRESBYTERIAN DALLAS Questions? 21
Editor's Notes
- #2: The project we chose was Surgical Care Improvement Project-VTE Prophylaxis 1 and 2 Core measures. VTE 1 is whether the appropriate prophylaxis was given and VTE 2 measures whether or not the prophylaxis was given.
- #3: In our project we were aiming to increase Inpatient SCIP VTE prophylaxis compliance to top decile.
- #4: Team members consisted of myself and Jen Caldwell from the Quality dept. We included physicians, nurses, a pharmacist and several people from the IT department.
- #6: We follow the PDSA method at THDallas. We will discuss each step in more detail in the slides ahead.
- #7: Currently VTE prophylaxis is ordered by physician, nurse administers VTE prophylactic, if no order on chart, nurse to call MD and obtain order or have documentation by MD to contraindications Inconsistent use of the SCIP checklist. Unclear ownership of check list Identify trends, implement standard process, educate staff on core measure and collaboratively develop corrective action measures to achieve consistency in compliance to core measure.
- #8: Identified lack of knowledge with VTE core measure and compliance Interview staff to identify obstacles Majority of nurses reported inconsistent use of SCIP checklist Review of order sets- inconsistent
- #10: We looked back over the last 12 months and we were able to identify our greatest area of opportunity and piloted the education materials and SCIP checklist on Main 6.
- #11: We did drill down on both surgery type and physicians. Again we found that the majority of surgeries and physicians were those that were on Main 6.
- #13: After the drill down, we piloted using the SCIP checklist tool. This tool guides the nurse through the various core measures to track and make sure completed on time. This tip sheet is one we created with the help of IT to educate the nurses on how to use.
- #17: This shows that as our education was rolled out, that the SCIP checklist was being used more.
- #18: With the increase use in the SCIP checklist, we had a increase in our VTE compliance. You will see that in October we had a fall out and when we went back to check, the checklist was not used.
- #20: Describe any barriers encountered
- #21: Problems/issues with the application of specific LSS tools Management of the Team/Team building Communications Organizational activities Other