PROJECT PROFILE - NYACP



HANYS’

2010 Pinnacle Award for Quality and Patient Safety

Submission Template and Guidelines

Section I:

A. Contact information required for publication and feedback. Please type in white space only.

|Required Information |Complete below: |

|Full Name |Susan Goldberg |

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| |RN, BSN, MPA |

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| |Assistant Vice President, Organizational Performance |

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| |Maimonides Medical Center |

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| |4802 Tenth Avenue |

| |Brooklyn, New York 11219 |

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| |718-283-8337 |

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| |sgoldberg@ |

|Credentials | |

|Title | |

|Organization Name | |

|Organization Address | |

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|Telephone | |

|E-mail | |

B. Check applicable submission category:

[ ] System or multi-level entity

[ X ] Large Hospital (> 100 mean daily patient census)

[ ] Small Hospital or Outpatient Organization

[ ] Division, Specialty, or Unit-based entity

C. Check if you are a Nassau-Suffolk Hospital Council (NSHC) member and would like this entry to also be submitted for the NSHC Annual Quality Award.

[ ] Yes

Section II: See brochure for directions. This project narrative section should be (1) written and reviewed for potential publication, (2) must not include any facility-identifying information for the judges’ review, and (3) cannot exceed this one page format using just the white space section, single spaced, and11 pt. Times New Roman.

|Information Required |Please Complete in This Column |

|Name of Initiative |Enhancing Quality and Patient Safety: Improving VTE Prevention Strategies and Patient |

| |Outcomes through the Development and Implementation of an Evidenced Based Risk Assessment |

|This section is between 25 and 30 words. |Tool and Standardized Prophylaxis Protocols. |

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|Project Description |Pulmonary embolism (PE) resulting from deep vein thrombosis (DVT) is the most common |

|(Narrative Summary) |preventable cause of hospital death. Given the Medical Center’s high risk population, in |

| |2004, a multidisciplinary team was formed to develop a hospital-wide VTE risk assessment |

|This section is between 150 and 225 words, depending on use of|and prophylaxis policy: |

|space and bullets. |A point based risk assessment was incorporated into the paper History and Physical. |

| |The American College of Chest Physician’s (ACCP) prophylaxis protocol was incorporated into|

| |our Computerized Physician Order Entry (CPOE) System. |

| |A reminder was added to the ordering pathway if no risk assessment was performed. |

| |Although compliance with our SCIP processes was over 90%, our outcome data had not improved|

| |to the degree we had anticipated. An analysis revealed a lack of practitioner understanding|

| |of the point based risk assessment. The Medical Center collaborated with the Agency for |

| |Healthcare Quality and Research (AHRQ) to improve our current process. In January 2009, the|

| |following changes were implemented: |

| |The assessment was simplified, eliminating the point system. Three categories of risk were |

| |identified: Low, Moderate and High. |

| |The risk assessment and ordering protocols were incorporated directly into the CPOE system.|

| |The assessment was made mandatory and admitting orders could not be entered unless it was |

| |completed. |

| |The CPOE pathway was revised to reflect the most current AHRQ/ACCP recommended guidelines. |

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|Outcomes Achieved |In 2009, as compared to 2007, there was a 43.8% decrease in the number of reportable DVTs. |

|Please use bullets |In 2009, as compared to 2007, there was a 32.8% decrease in the number of reportable PEs. |

|A one-page Word document can also be submitted containing one |NSQIP (National Surgical Quality Improvement Program) outcome data showed a downward trend |

|or more graphics. |of our surgical VTE rate. |

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|This section is approximately 60 words when using bullets. | |

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|Lessons Learned | |

|Top three lessons learned utilizing bullets. |Implementing standardized protocols is an effective means to reduce the incidence of DVT |

| |and PE. |

|This section is approximately 45 words when using bullets. |Early end user feedback prior to and following implementation of a new process is |

| |necessary. |

| |Physician consensus when utilizing evidenced based practice guidelines is essential for |

| |success. |

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Section III: Additional supporting information cannot exceed two pages. Please do not include identifying information for judges’ review.

|Information Required |Please Complete in This Column |

|Problem Statement |Given the Medical Center’s high risk population; 28% over the age of 75 with multiple co-morbidities, and a historically |

| |higher than average incidence of DVT and PE, an opportunity existed to improve the current VTE risk assessment process. |

| |An improvement in this process should increase compliance with ordering the recommended pharmacologic and mechanical |

| |prophylaxis protocols, resulting in a reduction in the number of DVTs and PEs. |

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|Aim-Goals |The goals of the project were to: |

| |Standardize the VTE risk assessment process and ensure that all admitted patients receive appropriate prophylaxis. |

| |Utilize our existing CPOE system to ensure that a mandatory VTE risk assessment is performed and that appropriate |

| |prophylaxis therapy is ordered. |

| |Reduce the incidence of DVT and PE. |

|Methodologies and Change | |

|Principles |The Department of Organizational Performance facilitated the project utilizing the PDCA Methodology. An opportunity for |

| |improvement was identified and a multidisciplinary team was organized with representation from the Department’s of |

| |Medicine, Surgery, Nursing, Pharmacy, Risk Management, and Performance Improvement. The existing process was clarified |

| |using process mapping/flow-charting and sources of variation were subsequently identified using control charts. An action|

| |plan was developed and implemented. In order to check the results, data was collected, aggregated, and analyzed. Ongoing |

| |review of process and outcome data was necessary to assess compliance and sustainability of improvement strategies. |

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|Additional Outcomes Not Listed |During the same time period there was a decrease in unplanned returns to the operating room due to DVT. There was also a |

|in Section II |decrease in surgical mortality, overall hospital mortality and overall average length of stay. Although we cannot make a |

| |direct correlation, we believe it is likely that a reduction in the number of DVT and PE was a contributory factor. |

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|Sustainability Strategies |The work of the VTE team was incorporated into the existing Quarterly Surgical Care Improvement (SCIP) Committee. |

| |Compliance issues, barriers to success, and proposed solutions continue to be vetted in this forum. SCIP process data and|

| |DVT outcome data are presented to the Committee. Accountability for adherence to established protocols and processes is |

| |stressed, and the Chairmen of the relevant Departments are actively engaged. |

| |A significant factor contributing to the overall success and sustainability has been active involvement of the Pharmacy |

| |and the IT/MIS Department from the inception and ongoing. Both Departments had representation on the implementation team.|

| |The Pharmacy Director’s expertise with regard to anticoagulant management and associated complications was invaluable. |

| |The Director collaborated with Medical leadership in the development of the prophylaxis protocols. The Medical Center is |

| |in the process of implementing a new electronic medical record system and the evidenced based functionality that existed |

| |in our original system is being replicated and enhanced in the new system. The IT/MIS Team continues to have leading |

| |roles in transitioning our prophylaxis protocols into the new system. The system will also be able to generate reports to|

| |validate compliance in a timely manner. |

| |A significant decrease in the incidence of DVT and PE should result in a reduction of patient complications, average |

|Business Case Information |length of stay, and mortality. That being said, cost reductions due to decreased utilization of resources are likely to |

| |follow. In addition, as outlined by CMS, it would be less likely that revenue reduction attributed to DVT as a |

| |Potentially Preventable Complication (PPC) would occur. |

|Conclusion, Recommendations, or|The organization will continue to monitor and evaluate compliance with the processes implemented. Early identification of|

|Next Steps |a breakdown in the process will assist in maintaining the gains. In addition, we have identified increased patient |

| |awareness and patient/ family education as another area of focus. We are in the process of reviewing and evaluating the |

| |effectiveness of our current educational efforts with regard to DVT prophylaxis, recognition of signs and symptoms, and |

| |ongoing anticoagulation management post discharge. |

A one-page Word document containing one or more graphics can also be submitted.

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