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1TEXAS HEALTH PRESBYTERIAN DALLAS04/18/23 1TEXAS HEALTH PRESBYTERIAN DALLAS

O.C.E

Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery

Quality ImprovementJen Caldwell & Kathy Moon

2TEXAS HEALTH PRESBYTERIAN DALLAS

Yellow Belt Presentation Outline

1. Cover Page

2. Charter

3. Process Current State or Baseline

4. Analysis Tools

– What analysis tool you uses- 5S, Poke Yoke, ect?)

5. Future State or Solutions

6. Results

– Final results – photo, chart, process map, etc

7. PDSA / Summary Slide

8. LSS Questionaire

2


THD Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery

Project Team:

Sponsor: Laura Weber Champion: Jen Rainer/ Suzanne Murphy

OCE Leader: Nergis Soylemez-Sayed

YB/GB Project Leader: Jen Caldwell & Kathy Moon

Team: Keith Turner, Jamie Caldwell, Mary Collins, Patti Marks, Theresa Lobmeyer, Dr. Eugene Hunt, LaVona Wilkes, Carol Gentry

Problem Statement:

Our THD score for the above measure reported to Leapfrog was 80% for 2012. This is only a snapshot of 100 cases, 80% is the minimal standard for Leapfrog.

Project Goals:

1) Develop educational tools for DVT Prophylaxis compliance for Cesarean section.

2) By October 15, 2013 measure a 10% increase in DVT Prophylaxis compliance.

3) Provide education to MDs, Nurses, and Patient Care Staff.

4) Increase unit by unit accountability for meeting DVT Prophylaxis Compliance for women undergoing Cesarean Section by performing monthly audits for the next 3 months.

Business Benefit:

1) Improved patient care/outcomes.

2) Improved Leapfrog reported data.

3) Improved hospital of choice for women undergoing Cesarean section based on publicly reported outcomes.

Business Benefit:

1) L&D

2) Finance

3) Public perception

Project Scope:

1) THD

4TEXAS HEALTH PRESBYTERIAN DALLAS 4

90% DVT Prophylaxis Compliance in Women Undergoing C-section

Inconsistent work flow

Man

Measurement Material

Method

Culture of approaching MDs if not ordered

Lack of MD buy in

SCDs need to be checked in Order

set

THR ran reports SCDs located in another room

Currently not audited on routine

basis

MDs not wanting to be told what to do

Lack of education regarding measure

inconsistent documentation

Several ways to do in work flow

Ishikawa


Patient is admitted for scheduled C -section

DVT Prophylaxis in Women Undergoing Cesarean Delivery

L&D RN Gets SCDs sleeves from Pyxis

SCDs are documented on Pre- procedure checklist and/or

OB admission assessment FlowSheet

Patient transported to L&D OR and

transferred to OR table

SCD machine turned on

L&D RN Puts SCD sleeves on patient

Orders C-Section Order Set in Care

Connect, checks box in order set for SCDs if

MD orders

L&D Nurse calls MD for orders

No DVT prophylaxis

Documentation on IntraOp tab in Care

Connect

MD orders SCDs ?

Process Current State

Yes

No

Inconsistentdocument both on flow sheet and

IntraOp


Analysis Tools

Benchmark– The Leapfrog Group annual survey targets 80% as the national

benchmark– The American College of Obstetricians and Gynecologists

(ACOG) published a bulletin in September 2011 addressing risk factors and prevention of venous thromboembolism(VTE) in pregnancy.

ACOG Issues Guidelines to Prevent Thromboembolic Events, Laurie Barclay, MD, August 26, 2011

– National Quality Forum (NQF) #0473 Appropriate DVT Prophylaxis in women undergoing cesarean delivery

6


Analysis of Cesarean Section Patients

7


Solutions

8

Concern/ Problem Solutions/Countermeasures

Inconsistent documentation Tip sheets made for staff, attended unit meetings

Lack of education Tip sheets made for staff, attended unit meetings

Lack of understanding of Leapfrog measure Educated staff during staff meetings

Unfamiliar with THR Policy : Peri-Operative Care of the Patient Undergoing a Cesarean Delivery

Educated on policy

Documenting in QRS QRS does not pull information in to CareConnect. QRS is to be used for fetal monitoring only

Lack of ownership Self audits done by L&D staff. L&D staff reported out findings at staff meetings


Results

9


Tipsheet for documentation of SCDs

10

2. CLICK ON OB ADM ASSESS

3. CLICK ON SCD

1. CLICK ON FLOW SHEET

The OB admin assessment is where the nurse documents when the SCD sleeves are put on the patient in the room, prior to arrival to the OR. It is the nurse’s responsibility to document that the sleeves were placed on pt and the OB admin assessment is the proper place to do so.


2. CLICK ON PRE-PROC CHECKLIST 1. CLICK ON FLOW SHEET

3. CLICK ON SCD

The pre procedure checklist records the fact that SCDs are present prior to entering the OR. That does not mean the nurse completing the pre procedure checklist is the same nurse that placed the SCD sleeves on the patient (most times this is the same nurse).




1. CLICK ON DELIVERY SUMMARY

2. CLICK ON C-SECTION

3. CLICK ON EQUIPMENT

The intra op tab is where the nurse documents the SCD sleeves are in place AND connected to the SCD machine in the OR, prior to surgery.



• The OB admin assessment is where the nurse documents when the SCD sleeves are put on the patient in the room, prior to arrival to the OR. It is the nurse’s responsibility to document that the sleeves were placed on and the OB admin assessment is the proper place to do so.

• The pre procedure checklist records the fact that SCDs are present prior to entering the OR. That does not mean the nurse completing the pre procedure checklist is the same nurse that placed the SCD sleeves on the patient (most times this is the same nurse).

BOTH, THE OB ADMIN ASSESSMENT AND THE PRE-PROCEDURE

CHECKLIST, FLOW INTO THE FLOWSHEET. One of the above must be completed in addition to the intra op record.

• The intra op tab is where the nurse documents the SCD sleeves are in

place AND connected to the SCD machine in the OR, prior to surgery.

14TEXAS HEALTH PRESBYTERIAN DALLAS04/18/23 14TEXAS HEALTH PRESBYTERIAN DALLAS 14

DVT Prophylaxis in Women Undergoing Cesarean DeliveryJen Caldwell, Kathy Moon, Keith Turner, Jamie Caldwell, Dr. Eugene Hunt, LaVona Wilkes,

Theresa Lobmeyer, Carol Gentry, Patti Marks, Mary Collins

State Date: 1/27/2013Problem Statement:Our THD score for the above measure reported to Leapfrog

was 80% for 2012. This is only a snapshot of 100 cases and 80% is the minimal standard for Leapfrog.

Project Objectives: • By October 15, 2013 measure a 10% increase in DVT

Prophylaxis compliance. • Provide education and educational tools to MDs,

Nurses, and Patient Care Staff.• Increase unit accountability by having frontline nurses

performing monthly audits for the next 3 months.

SCOPE: Texas Health Presbyterian Dallas

• Continue education and reinforce documentation to hardwire process

• Feedback to bedside nurses who perform audits• Monitor overall improvement

• Used Ishikawa to identify opportunities• Developed educational tools to increase documentation compliance• Department Chair educated physicians regarding practice, policy, and current recommendations• Educated nurses and patient care staff • Involved bedside nurses to perform audits Audit results monthly• Continue to educate nurses and patient care staff at monthly meetings• Provide graphs to staff for “Visual Controls” • Feedback from nurses regarding documentation challenges

IMPROVE/ CONTROL (ACT)

DEFINE (PLAN) MEASURE/ ANALYZE (DO/ CHECK)

SAVINGS/ BENEFIT• Improved patient care/outcomes.• Improved Leapfrog reported data.• Improved hospital of choice for women undergoing

Cesarean section based on publicly reported outcomes.


Lean Six Sigma Belt Questionnairefor the Scoop

1. Please write two-three sentences to explain your project:

2. Answer one of the following:

• Why did you decide to pursue LSS certification?

Kathy and I had the opportunity to take a Clinical Safety and Effectiveness course at UTSW more than a year ago. This class covered both quality tools and Lean Six Sigma concepts that we both enjoyed learning. Working in the Quality Department, we were both excited to be formally trained in LSS as this will help us both with process improvement and quality metrics.

Or

• What was the most important thing you learned from LSS?

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By using Lean Six Sigma Tools, our team first brainstormed to identify challenges, developed an Ishikawa diagram, and performed a “Gemba”/walkthrough of the process. After identifying opportunities, we developed educational tools to assist with documentation, provided education to both nurses and physicians, and promoted ownership by having L&D frontline staff perform monthly audits. Visual controls were provided in the form of graphs and reviewed monthly in staff meetings. Through these methods we were successfully able to increase DVT Prophylaxis of Women Undergoing Cesarean Section by 10%.

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