Hospitals are complex systems. Over time, each hospital accumulates its own set of care processes—some coordinated, some autonomous—that directly affect inpatient outcomes. As systems, hospitals are perfectly designed to achieve exactly what they do; thus, improving the output of a hospital requires change.
Not all change results in improvement, however. Recently, several systematic reviews have attempted to gauge the efficacy and effect of quality improvement strategies, but research in hospital care delivery has yet to elucidate a transferable strategy to deliver optimal care on a consistent basis.1-3 A review of quality improvement studies published in major journals in the United States found that three-quarters of them used simple before-and-after designs, often at single sites within single centers, making it challenging to attribute observed benefits to the studied intervention.4 The state of the science suffers from more than a lack of rigor in study design. The choices of particular interventions fundamentally lack compelling theories that can predict success.5 While a taxonomy for quality improvement strategies was recently derived from one of these systematic reviews, the literature still does not reflect adoption of standardized language to articulate the mechanisms underpinning performance improvement.6
Until research in hospital care delivery is able to elucidate transferable strategies to deliver optimal care on a consistent basis, quality improvement (QI) practitioners, such as physicians, pharmacists, nurses, and risk managers, must rely heavily on experience and ingenuity. The same skills critical for driving actual improvement in the hospital—designing, managing, and leading change successfully over time—are also commonly missing from clinician skill sets. This guide, derived primarily from principles of QI and personal experiences, is designed to help the QI practitioner lead an efficient, reliable effort to improve prevention of one of the most important problems facing hospitalized patients, hospital-acquired venous thromboembolism (VTE).
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A Preventable Problem
Pulmonary embolism resulting from deep vein thrombosis (DVT)—collectively referred to as VTE—is the most common preventable cause of hospital death.7-9 Fortunately, pharmacologic methods to prevent VTE are safe, effective, cost-effective, and advocated by authoritative guidelines.10 Yet, despite the reality that hospitalized medical and surgical patients routinely have multiple risk factors for VTE, making the risk for VTE nearly universal among inpatients, large prospective studies continue to demonstrate that these preventive methods are significantly underutilized.11-15
The Agency for Healthcare Research and Quality calls thromboprophylaxis against VTE the "number one patient safety practice."16 The American Public Health Association has stated that the "disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis."17 While individual centers have published results of successful local initiatives for improving prevalence of VTE prophylaxis, no single strategy has proven yet to be effective, sustainable, and widely applicable to other centers. This is evolving rapidly, as experience with local efforts and the Society of Hospital Medicine's Venous Thromboembolism Prevention collaborative are validating the risk assessment techniques and implementation techniques presented here. One thing is certain, however. To implement effective protocols minimizing incidence of hospital-acquired VTE, while at the same time minimizing adverse outcomes, redesign is needed in both care delivery and performance tracking.
Ideas for what to change, how, and how to manage change successfully over time should come from a local improvement team, ideally a selection of established or emerging leaders with experience as frontline caregivers or complementary insights. Members of this multidisciplinary team should have knowledge of the evidence base, local influence or insight into care delivery, or a framework for leading QI. In a growing number of hospital systems, hospitalists are prime candidates to lead such teams.
Essential elements to reach breakthrough levels of improvement in care include:
- Institutional support and prioritization for the initiative, expressed in terms of a meaningful investment in time, equipment, personnel, and informatics, and a sharing of institutional improvement experience and resources to support any project needs.
- A multidisciplinary team or steering committee focused on reaching VTE prophylaxis targets and reporting to key medical staff committees.
- Reliable data collection and performance tracking.
- Specific goals or aims that are ambitious, time-defined, and measurable.
- A proven QI framework to coordinate steps towards breakthrough improvement.
- Protocols that standardize VTE risk assessment and prophylaxis.
- Institutional infrastructure, policies, practices, or educational programs that promote use of the protocol. The protocol that standardizes VTE risk assessment is so fundamental that it must not merely exist. It must be embedded in patient care. High-reliability design should be used to enhance effective implementation.
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How to Use This Guide
QI projects should always develop from recognition of a gap between optimal care and care that is actually being delivered. In its progress, QI unfolds along several parallel fronts. Many steps in an initiative occur simultaneously and are often interdependent. This guide offers a framework to help the QI practitioner achieve important milestones along the path to breakthrough levels of performance. The guide presents chapters that match the logical steps of a QI project:
- Take essential first steps.
- Lay out the evidence and identify best practices.
- Analyze care delivery.
- Track performance with metrics.
- Layer interventions.
- Continue to improve.
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