Hospital Acquired Thrombosis Collaborative Guide

Welcome to the 1000 Lives Plus Collaborative on Hospital Acquired Thrombosis

In this handbook, you’ll find information that will help you plan for your participation in the Hospital Acquired Thrombosis (HAT) Collaborative.

TABLE OF CONTENTS

GENERAL INFORMATION ...................................................................... 4

COLLABORATIVE CHARTER ................................................................... 5

COLLABORATIVE LEADERSHIP ............................................................... 7

SET AN AIM ...................................................................................... 8

IDENTIFYING LEADERSHIP AND CHOOSING YOUR TEAM ................................ 8

MEASURES.......................................................................................10

MEASUREMENT ASSIGNMENT 1..............................................................13

REGISTERING WITH THE 1000 LIVES PLUS AND THE COLLABORATIVE’S EXTRANET15

WHOM TO CONTACT ..........................................................................15

LS1 PRE WORK – TO CONSIDER BEFORE LS1 .............................................16

LS1 PRE WORK – TO BRING ALONG TO LS1...............................................18

MEASURE SETUP ...............................................................................19

MEASUREMENT PROCESS.....................................................................19

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Team Preparation Checklist Tasks

Review these materials and identify the individuals who will be

working on this improvement effort. Distribute copies of these materials to the front line team.

Meet with your organization's senior leadership to determine

direction for your aim and to arrange needed resources for the team.

Convene the initial site team to develop specific aims. Collect and review information on service in your organization Register with the IHI website at

http://www.ihi.org/about/siteregistration.asp

Register for Learning Session #1 Undertake Pre work: summary of aim, team, and initial measures

for Learning Session #1. Pg 16 onwards

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General Information

Overall Structure of the 1000 Lives Plus Collaborative on Hospital Acquired Thrombosis

The Collaborative will involve eight organisations working together intensely for twelve months. During that time, Collaborative organisations will participate in three one day Learning Sessions and maintain continual contact with each other and faculty members through email, conference calls, and site visits. Note: Email and the Internet are a primary means of communication among Collaborative participants. We strongly urge those who do are not currently subscribed to the programme extranet do so.

Learning Sessions

Learning Sessions are the major integrative events of the Collaborative. Through plenary sessions, small group discussions, and team meetings attendees have the opportunity to:

• Learn from faculty and colleagues • Receive individual coaching from faculty members • Gather new knowledge on the subject matter and process improvement • Share experiences and build collaboration on improvement plans

Schedule for the Learning Sessions Learning Session #1

Learning Session #2

Learning Session # 3

12th Jan 2010, MRC, Llandrindod Wells

8th June 2010, Mid Wales venue

16th Dec 2010 Mid Wales venue

Between Learning Sessions

The time between Learning Sessions is called an Action Period. During Action Periods, Collaborative participants work within their organisations towards major, breakthrough improvement. Although participants focus on their own organisations, they remain in continuous contact with other Collaborative participants and faculty. This communication takes the form of conference calls, email, and site visits to other organizations in the Collaborative. In addition, Collaborative participants share the results of their improvement efforts in monthly reports. Participation in Action Period activities is not limited to those who attend the Learning Sessions. We encourage and expect the participation of your other team members in Action Period activities.

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Collaborative Charter

1000 Lives Plus Collaborative on Hospital Acquired Thrombosis

Problem Statement In 2005, The Health Select Committee identified that VTE “is the immediate cause of death in 10% of all patients who die in hospital. The figure exceeds the combined total of deaths from breast cancer, AIDS and traffic accidents. It is over twenty five times greater than the 9554 annual deaths from MRSA and more than five times the total of all hospital acquired infections. The total cost (direct and indirect) to the UK of managing VTE is estimated at £640 million. Even more alarming than the scale of the problem is the fact that VTE in hospitalised patients is largely preventable through the use of thromboprophylaxis during the hospital stay of the patient and, in some cases, continuing after discharge. A study in over 4,000 patients who died of PE following major surgery, demonstrated that the use of perioperative low dose heparin reduced the frequency of fatal PE from 8 per 1000 to 1 per 1000 patients operated on — saving 7 lives per 1000 patients operated on. Thus thousands of lives could readily be saved by the use of a tried and tested treatment” (House of Commons Report 2005).

Mission In this Collaborative, the mission of the 1000 Lives Plus and participating health care organisations is to work together to develop a systematic approach to HAT prevention to reduce avoidable death and harm in hospital patients in Wales. This will be achieved through the Collaborative by the implementation of the All Wales Risk Assessments and appropriate prophylaxis for all in-patients in Wales. The Collaborative will strive to meets its goals, in twelve months, by sharing ideas and knowledge, sharing methodologies for change, implementing proven concepts, and measuring change

Collaborative Goals Goals for participating organisations that are consistent with this mission include:

• Reduce incidents of HAT by 50% in 18 months • Achieve 100% compliance with risk assessment and prophylactic treatment of in

patients by December 2010 • Raise awareness among professionals and the public of HAT prevention and the

All Wales Risk Assessment • Engage with all healthcare professionals, senior managers and doctors in

implementing HAT risk assessment in local hospitals and in assessing compliance across the NHS

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• Develop better measures and feedback mechanisms on HAT in hospitals • Raise awareness of HAT prevention in primary care and the community in

general. These goals will be considered by the collaborative at the first meeting.

Methods Each organisation is expected to state and accomplish a specific goal relating to the implementation of the Hospital Acquired Thrombosis risk assessments and prophylaxis. Organisations should focus initially on a patient population, for example orthopaedic patients; a specific ward; or a specific team. To measure progress towards their goal, most organisations will have to develop a measurement strategy. For this Collaborative, organisations will need to complete monthly reports (via the extranet) and should begin to consider ways of gathering data monthly such as using risk assessment forms filled out as patients are admitted or follow up inspection of notes.

Collaborative Expectations The 1000 Lives Plus, the Collaborative Chair, and the programme manager specialist will:

• Provide information on subject matter, application of that subject matter, and methods for process improvement, both during and between Learning Sessions

• Offer coaching to organisations • Provide communication strategies to keep organisations connected to the

faculty and colleagues during the Collaborative

Participating organisations are expected to:

• Provide a senior leader to serve as sponsor for the team working on the Collaborative

• Send a team to all Learning Sessions • Provide the resources to support their team, including resources necessary

for Learning Sessions, time to devote to this effort, support for measurements and active senior leadership involvement

• Perform tests of change leading to process improvements in their organisation

• Share information with the Collaborative, including details of changes made and data to support these changes, both during and between Learning Sessions

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Collaborative Leadership

Chair Dr Simon Noble, Palliative Care Consultant, Aneurin Bevan LHB

Director Professor Jonathon Gray Faculty members Dr Simon Noble, Palliative Care Consultant, Aneurin Bevan LHB Programme Manager Peggy Edwards, Patient Safety Manager, NPSA

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Set an Aim An aim is an explicit statement summarizing what your organisation hopes to achieve during the Collaborative. For example, an aim might be to reliably use the checklist for 95% of elective cases.

In setting your aim, be sure to do the following:

1. Involve senior leaders

Leadership must align the aim with strategic goals of the organisation.

2. Base your aim on data Examine compliance data within your organisation. Refer to the goals in the Collaborative Charter and focus on issues that matter. See section on Measures in How To Guide.

3. State the aim clearly and use numerical goals Teams make better progress when they have unambiguous, specific aims. Setting numerical targets clarifies the aim, helps to create tension for change and directs measurement. For example, an aim to “increase patient satisfaction with referral process to home care services by 50% in 8 months” will be more effective than the aim “to improve service.”

Identifying Leadership and Choosing Your Team

This Collaborative will be building upon the ongoing change in organisation's cultures and infrastructures resulting from the involvement in the 1000 Lives Plus. It is critical to have at least one clinical champion on the team. This champion should have a good working relationship with colleagues and with the day-to-day leader(s) described below and should be interested in driving change in the system. Look for clinicians who are opinion leaders in the organisations - an individual that others go to for advice and someone that is not afraid to try new ideas.

Senior Leadership Roles

The executive sponsors the collaborative team; they are a senior manager who creates the vision and an executive level person in charge of spreading specific changes in the service throughout the organisation or system.

Front Line Teams You should choose which specific wards or departments in the organisation to begin your work in. Guidance on what areas to choose is included in each of the team examples below. Having appropriate and effective teams is a key component of successful improvement efforts. Your Front Line Teams should be larger than just the core individuals who attend all of the Learning Sessions, but not so large as to

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make it difficult to get work done. Five to six individuals are a good size for the team.

Day-to-Day Leadership

A day-to-day leader is the critical driving component of the project, assuring that tests are implemented and overseeing data collection. It is important that this person understands not only the details of the system, but also the various effects of making change(s) in the system. This person also needs to be able to work effectively with the physician champion(s).

The day-to-day leader will be Collaborative “key contact” at your organisation. This individual should be responsible for coordinating communications between the team and the Collaborative.

Learning Session Attendees: Who should come to Learning Sessions?

Choose the five individuals who can work together effectively, learn the methodology, and plan for action upon returning to your organisation. We have developed the following guidelines from past Collaboratives to help you determine who should attend the Learning Sessions.

• The day-to-day leader(s) should be at all three Learning Sessions.

• The champion(s) should be at all three Learning Sessions.

• Representatives of the professional groups who will be involved in the implementation of the risk assessment e.g. nurses and pharmacists.

Each learning session builds on the previous one and to ensure continuity in the team, it is recommended that the same members attend each time. As your organisation begins to spread the successful work of the Front Line Teams in each Content Area you may want to substitute a few individuals, but in the initial stages of the work it is important for the same individuals to continue to attend. Characteristics of a Good Team Member In selecting team members, consider the following characteristics. For each potential team member ask the following: • Is the person respected for their judgment by a range of staff? • Do they enjoy a reputation as a team player? • What is the person’s area of skill or technical proficiency? • Are they an excellent listener? • Is this person a good verbal communicator within and in front of groups? • Is this person a problem-solver? • Is this person disappointed with the current system and processes and

passionately wants to improve things? • Is this person creative, innovative, and enthusiastic? • Are they excited about change and new technology?

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Your best approach to selecting a team is to rate potential team members on each of the above attributes. While you may start with a list of ten or more candidates, the goal is to identify the five to six who best represent these characteristics and work well together. It may also be helpful to consider characteristics of the team as a whole, for example, • Are there different learning and / or behavioural styles among team members

that may complement each other or cause difficulties within the team? • What might be the tensions/difficulties within the team? • Can the team members participate in safety briefings and meet regularly? See later section for plan. MEASURES

The Why, What, and How Much of Measurement

This Collaborative is about improvement in service, not measurement. But measurement will play a number of important roles throughout the Collaborative. Measurement is required to assure that everyone stays aware of changes in level of service or perceptions of service. In this Collaborative, measurement will help us evaluate the impact of changes we make to improve service in the health care system. Always remember that measurement should accelerate improvement not slow it down. Your team needs just enough measurement to be convinced that the changes you are making are leading to improvement.

Top tips Key things to remember when starting to measure:

• Seek usefulness not perfection - measurement should be used to focus and speed improvement up not to slow things down

• Measure the minimum. Only collect what you need; there may be other information out there but the aim is to keep things as simple as possible

• Remember the goal is improvement and not a new measurement system. It’s easy to get sidetracked into improving data quality, especially if you are confronted with challenges on the credibility of the data (more commonly from colleagues who may tend to trust more rigorous research data) – just ensure it’s ‘good enough’

• Aim to make measurement part of the daily routine. Where possible use forms or charts that are already routinely used or add recording /collection process to one that is already in place. This minimises the burden on staff and also maximises the chances of it being done reliably.

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• Don’t let measure issues delay the start of your PDSA cycles. Your first few cycles should be so small that they won’t affect your baseline.

The 7 steps to take

Steps 1 to 3 – Getting yourself ready Step 1 – Decide your aim The key points to remember about aim setting are:

• Those involved in making the changes should be able understand (and translate) the project work to the strategic goals.

• The aim statement should be unambiguous clear, specific, numerical, measurable – it MUST state ‘How much’ and ‘By when’.

• If the aim seems quite along way from where your current performance level (baseline) is, it is advisable to break it down into statements that make it seem more achievable e.g. achieving 80% compliance within 1 year but improving this to 95% within 18 months.

Step 2 – Choose your measures Although the How to Guide for the Hospital Acquired Thrombosis gives you an overarching measure for the intervention; % documented risk assessment, the programmes Extranet site also allows you to create your own custom measures so that you can choose measures that you feel are important to you locally.

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Step 3 – Confirm how you will collect your data You will need to identify the data you need and where it comes from. Sometimes some of the data will be already collected but often you may need to set about collecting it yourself. The process of working this out helps you to define exactly what is you are measuring and sometimes you will find that it might be so complex that you need to rethink what the best measure is to ensure the data is collected reliably. It also can help you add detail to your aim statement such as what the pilot population is if you are using one. The Collect-Analyse-Review (CAR) measurement cycle Measurement itself is a process. In its simplest form it consists of three stages. First you collect some data, then you analyse it and present in an appropriate way to convert it into useful information and finally you review your information to see what decisions you need to make. The CAR cycle then starts all over again. Step 4 – Collect your baseline data You will need to know your baseline before you can track the progress of your goal against it. By starting your measurement and plotting points you will be able to create your baseline. To create a baseline or identify a trend using a run chart, about 25 data points are ideal. However, 20 data points will provide a robust representation. One way to get more points is to measure more frequently. The Campaign measures have been set up on the assumption of monthly reporting. Obviously to get a robust baseline means you will need between 1 and 2 years of monthly data. Often the data you need to measure though is not being collected. If so you should start collecting your data straight away. But you do not have to wait to start testing small changes. They will not affect your overall situation so you can be doing those while creating your baseline. It will be useful to collect a baseline before attending the first learning session – do you know how many risk assessments you have in place, or how many different protocols there are? Step 5 – Analyse and present your data Use the Extranet The Extranet is a web-base based reporting tool set up especially by the Institute for Healthcare Improvement (IHI) for 1000 Lives Plus. Then all you have to do is enter your data and run charts are created for you automatically. You can also see the charts for other Trusts although the ability to actually input and change data is restricted to those individuals that each organisation has nominated. When entering your data there is also an opportunity to annotate the chart. This is an extremely useful way of noting when you have made changes so that you can see whether they are having any effect.

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Step 6 – Review your data to decide what it is telling you It is vital that you set time aside to look at what your measures are telling you. This can be incorporated into your prorgamme group meeting if you have one or other regular meetings. If you don’t have an existing meeting that includes the right people, you will need to set one up. It needn’t be a long meeting, 30 minutes is perfectly adequate to review where you are and decide the next actions. Remember that the purpose of measurement is to lead you to making the right decisions about your improvement project. Step 7 – Keep going Repeat steps 4,5 and 6 each month or more frequently.

It is important to begin organising data prior to the first Learning Session. At the session, we will discuss ongoing measurement strategies. Expect to plot some measurements on a monthly basis throughout the Collaborative.

Measurement Assignment 1

Here are some things to consider to keep measurement simple and effective:

1. Plot date over time. Improvement in service will require testing and implementing throughout the Collaborative. Most of the information about performance of your system and how it has improved can be learned by observing trends and patterns in simple time series charts of key measures directly related to the aim. Annotated run charts (time order plots) will be the minimum standard for the Collaborative.

2. Focus on measures of service directly related to your aim. One to three

measures that can be used to evaluate performance of the system relative to your team’s aim should be maintained throughout the Collaborative and reported on a regular basis. Additional balancing measures (measures that track the effect that changes in one part of a system have on other parts of the system) and measures of specific components of your system may be required at different times during the Collaborative, but these do not need to be reported regularly.

3. Use sampling. It is not necessary to have data on every patient or every service experience in your system. Appropriate sampling procedures should be developed to minimize the cost of data collection and measurement.

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4. Integrate measures into routine processes. Whenever possible, collect useful data as part of the normal performance of a process. Develop simple data recording forms that are integrated into the job.

Learning Session 1 Logistics Location: Media Resource centre,

Llandrindod Wells

Program Begins: Tuesday, 12th Jan at 9.30 a.m. Program Ends: Tuesday, 12th Jan at 16.30 pm Learning Session 1 Aims Although the 1000 Lives Campaign has now been in existence for nearly two years, the development of this collaborative is new and may involve teams or individuals that are new to the methodology. Therefore part of Learning Session 1 will be revisiting and building upon the skills and knowledge of improvement methodology, in particular, how this can be applied rapidly to a new intervention. The Learning session will give teams the time and support to develop and refine their aims, measures and first tests of change. It will also set the challenge of what can be done ‘by next week’. Pre work materials will be distributed prior to the learning set to start teams thinking about the way forward.

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Registering with the 1000 Lives Plus and the Collaborative’s Extranet In order to facilitate communication among collaborative participants, 1000 Lives Plus has developed an extranet for all members of the Collaborative. The first step in accessing the extranet is to register with the IHI web site. You can do this by: 1. Going to http://www.ihi.org/about/siteregistration.asp 2. Enter all of the required contact information 3. Choose a password that you will use to access the extranet 4. Click on the Submit Site Registration button Once you have registered with the site, you can access the extranet by going to http://www.ihi.org/extranet Here you will be able to: • Access supporting materials • Find out about conference calls • Enter monthly reports • Post documents for members of the Collaborative to view You will learn more about these features at the Learning Session.

Whom to Contact

The LS logistics and questions regarding your organization’s goals, team, progress may be addressed to:

Peggy.edwards@npsa.nhs.uk

Questions regarding improvement techniques and measures may be addressed to your local improvement advisor

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LS1 Pre Work – to consider before LS1

Who has responsibility for this intervention at a senior leadership level within your organization? How will you ensure that they are kept up to date with your work (walkrounds, data reporting)?

Who is your clinical champion? How often and where will you meet in order to plan the progress for this programme?

How will you explain the Risk Assessment tool to your multidisciplinary team?

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How could you incorporate a risk assessment into your admission process?

Who will be supporting you in reviewing feedback (eg. radiology). How often will the review take place? How will you communicate feedback to the rest of the team?

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PAGE

LS1 Pre Work – to bring along to LS1

Our goals include: (your measures – it answers the second question of the Model for

Improvement. Here they are stated as numeric goals )

AIM Worksheet – first draft to LS1

The (name of your specific organisation/team)

________________________________________________________________

intends to accomplish (This is a general over arching statement describing what you

intend to accomplish during the time you work on this process – it answers the first

question of the Model for Improvement. The process is identified in the statement, any

specific or segmented area is mentioned and words like improve, reduce, and increase are

often utilized)

________________________________________________________________

________________________________________________________________

________________________________________________________________________

________________________________________________________

by (time frame, i.e. month/year in which you intend to accomplish improvement)

________________________________________________________________

for (what group are you doing this for – who is the customer)

________________________________________________________________

because ( the rational and reasons to work on this improvement project)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________

•

•

•

•

18

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Measures checklist – first draft to LS1 Measure setup Measure name:

What data item comprises the Numerator?

What data item comprises the Denominator? (Some measures do not require one)

What is the calculation?

Mea

sure

def

init

ion

Which patient groups are to be covered?

What is the numeric goal you are setting yourselves?

Who is responsible for setting this?

Goa

l set

ting

When will it be achieved by?

Measurement process Is the data available?

Currently available / Available with minor changes / Prospective collection needed

Who is responsible for data collection?

Colle

ct

What is the process of collection?

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What is the process for presenting results? Eg enter data in Extranet, create run chart in Excel

Who is responsible for the analysis? Anal

yse

Calc

ulat

e m

easu

re a

nd

pres

ent

resu

lts

How often is the analysis completed?

How often are the results going to be reviewed?

Who is going to review the results?

Revi

ew

Who is responsible for taking action?

Register contacts

We will need to contact key people in your teams through the programme. To ensure that all communications are as effective as possible, please complete the following details and return to 1000livescampaign@wch.wales.nhs.uk

Organisation:

Name and Job Title

Email Address

Key Contact for collaborative (day-to-day leader):

Clinical Champion

Team member

Team member

Data Coordinator:

Many thanks

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