N715PE Final Project-Quality Management

1. Running head: FINAL PROJECT 1
Final Project
Josephine Villanueva
American Sentinel University

2. FINAL PROJECT 2
Final Project
A clinical issue and quality improvement initiative identified was to reduce hospital
acquired (HA) venous thromboembolism (VTE). Deep venous thrombosis (DVT) is a blood clot
in a large vein, usually in the leg or pelvis. DVT could disengage and become mobile in the
blood stream and could move through the heart and to the lungs and block an artery supplying
blood to the lungs triggering pulmonary embolism. The disease process that comprises DVT
and/or pulmonary embolism is called venous thromboembolism (VTE) (Streiff, Brady, Grant, et
al, 2014).Each year in the United States, estimated 350,000–900,000 persons develop incident
VTE, of who approximately 100,000 die, mostly as sudden deaths, the cause of which often goes
unrecognized. About 10%–30% of persons who live the first occurrence of VTE develop another
VTE within 5 years (Kyrle, Rosendaal, & Eichinger, 2010).
VTE is an outcome from three pathogenic mechanisms: hypercoagulability (increased
tendency of blood to clot), immobility or slow blood flow, and vascular injury to blood vessel
walls. Distinct characteristics include congenital and acquired factors, such as advanced age or
cancer, and interact with external factors, such as hospitalization or surgery. Hospitalization is a
major risk factor in the last two mechanisms; injury and surgery are sources of vascular injury,
and lengthened bed rest can cause stasis. Approximately half of new VTE cases transpired
during a hospital stay or within 90 days of an inpatient admission or surgical procedure, and
many are not detected until after discharge (Streiff, Brady, Grant, et al, 2014). Federal agencies,
such as AHRQ and CMS, and professional organizations, such as the Joint Commission and the
National Quality Forum promote numerous patient-safety quality or performance measures with
events associated with VTE. Hospital Acquired VTE reviews and studies conducted by the
Institute for Healthcare Improvement using hospital patient chart reviews to identify adverse

3. FINAL PROJECT 3
events, VTE was a fairly frequent cause of harm (eight events per 1,000 stays) and accounted for
one out of 17 preventable deaths (Landrigan, Parry, Bones, et al 2010). As part of VTE
prevention, patient care assessment, admission timeout was developed and implemented as
checklist of best practices for the management of VTE to ensure patient receives appropriate
venous thromboembolism (VTE) prophylaxis and document that each step was completed or was
not applicable.( See admission timeout). The process of Venous Thromboembolism (VTE)
Prevention (see flow chart) was reviewed with Quality Director and Donabedian’s Matrix for the
classification of quality measure applied. (See chart).
VTE prevention strategy developed will be focusing on compulsory VTE-prevention risk as
part of patient care assessments using the admission timeout checklist. Clinicians must recognize
VTE risk factors and contraindications to prophylaxis and must order risk-appropriate VTE
prophylaxis; During patient’s hospital stay, risk factors must be reassessed. Our organization’s
quality improvement committee’s goal must measure performance regularly to promote
continuous improvement by collect patient and clinician’s data to monitor performance; adverse
outcomes like hospital-acquired VTE and bleeding will be monitored.
Dr. Avedis Donabedian presented his model for classifying different means that will
measure the quality of healthcare in a given setting. Donabedian model provided an outstanding
structure for theorizing quality in a comprehensive manner and categorizing the measures that
one can use to assess different features of the quality of care (Sollecito, & Johnson, 2013).
Donabedian had differentiated three aspect of care as follows: The structure that refers to the
resources available to provide adequate health care. These resources include facilities, equipment
and trained personnel. The process denotes activities of giving and receiving care example could
be patient activities looking for care and given care of practitioner. The last aspect of care refers

4. FINAL PROJECT 4
to outcome that discusses mainly changes in patient’s condition following treatment; it also
includes patient knowledge and satisfaction (Donabedian, 1980).
The Quality Director in our facility continuously reminds us that VTE prophylaxis is not a
complicated process. The key thing to remember is to do basically a risk assessment on all adult
patients because about 90% of patients who are hospitalized on a medical service should get
pharmacologic prophylaxis; only about 10% may be low risk or have a contraindication to
heparin. The major risk factors includes acute medical illness like cancer, congestive heart
failure; COPD exacerbation; acute ischemic stroke; acute neurologic disease; inflammatory
bowel disease; inherited or acquired hypercoagulable condition, immobilization, obesity, and
certain medications (Streiff, Brady, Grant, et al, 2014). The Quality Improvement team
emphasizes the regimen for prophylaxis therapy for moderate and high risk patients is the same,
unless the patient at risk of bleeding is greater than the risk of clotting since anticoagulant like
Heparin is contraindicated with patient having serious bleeding in the past couple of weeks or a
low platelet count (less than 50,000) .It also is important to remember to prescribe mechanical
prophylaxis for patients at increased risk who have a contraindication to heparin and to reassess
the risk of bleeding as the hospitalization proceeds (McKean, 2010).
Donabedian’s Matrix for the Classification of Quality Measures allows us to value the
effort involve in defining and measuring quality of health care and provides guidance in aspect
of care that needs to be measured. The approached was applied in our organization to classify
quality measure to meet venous thromboembolism (VTE) prophylaxis criteria. Donabedian had
developed the definition of quality to include not just the technical management of the patient

5. FINAL PROJECT 5
but also the management of interpersonal relationships as well as access to care and continuity of
care (Donabedian, 1980).
Donabedian Matrix for the Classification of Quality Measures Applied to VTE Prevention
Structure Process Outcomes
Accessibility  Availability of
bed; Admission
from ER to
Inpatient status
 Waiting time from ER to
floor transfer exceeds 60
minutes
 Patient satisfaction
with accessibility
Technical
Management
 Compulsory
assessment of
VTE risk patient
using Admission
Time out
 Policies &
Procedures
 Resources
 Identify types of
prophylaxis ordered
 Recognize VTE risk
factors
&contraindications to
prophylaxis
 Computerized Physician
Order Entry
 Computerized staff
documentation of
contraindication
 Pharmacy/Hospitalist
Anticoagulant Protocol
Management
 Administration of
medication accdg.To
standard
 Application of
appropriate VTE
prophylaxis
will prevent VTE
 AHRQ results in
comparison with
other organization
 Inpatient Satisfaction
Scores measured by
HCAHPS
Management of
Interpersonal
Relationships
 Staff
Collaboration
 Leadership
Support
 Nursing
Competency
 Develop
Multidisciplinary team
(RN, ARNP, physician,
Pharmacy, Nutritionist)
 Education of staff and
patients
 Staff and patient
satisfaction with
regards to VTE
prevention
Continuity (Quality
Care)
 Apply evidence
based practice  Data Collection
 Review compliance
 Monitor adverse
outcomes
 Incident surveillance
reporting
 Performance
Improvement
measured regularly
to promote
continuous
improvement.

6. FINAL PROJECT 6
Accessibility with regards to admission process in our facility; patients are seen in
Emergency Room prior to transfer to our department after level of care determine in the inpatient
setting. Outcome would depend on patient satisfaction with accessibility, depending on wait
times.
Technical Management structure consist of compulsory assessment of VTE risk patient
using Admission Time out implemented, Revision of policy and procedure to adapt VTE
prevention process and adequate use of resources. The process includes the identification of
types of prophylaxis ordered. It is important for clinicians to recognize VTE risk factors
&contraindications to prophylaxis. Computerized Physician order entry and staff documentation
of contraindication established. Clinician administration of medication according to standard is
essential. Pharmacy and Hospitalist management of heparin infusions improves the time to
achieve target laboratory values, the time that test values are within the target range and
appropriate laboratory-test ordering. The use of real time guidance in the computerized
prescriber-order-entry (CPOE) system protocol reduce the opportunity for erroneous, unguided
orders, methods using protocol driven order sets to initiate treatment with low-molecular-
weight heparin (LMWH), or warfarin , active monitoring, education (should include of
production of information guides for patients and consumers on how to prevent blood clots and
dangers to be aware of when taking blood thinners) (Maynard, Humber, & Jenkins, 2014).
Outcome would be reflected on AHRQ results and Inpatient Satisfaction Scores measured by
HCAHPS. Application of appropriate VTE prophylaxis will prevent VTE.
Management of Interpersonal Relationships structure concentration was on staff
collaboration, leadership support and nursing competency. Multidisciplinary team established in

7. FINAL PROJECT 7
our facility consist of Physician, RN, ARNP, Pharmacy, Hospitalist, and Nutrition services;
clinicians and healthcare organization play an important role in preventing hospital acquired
VTE event as part of patient safety quality improvement initiative. Education sessions on VTE
prevention for hospital clinicians through fairs, huddle and in-services. Teaching patients how
not to acquire VTE and develop VTE prophylaxis standards for their service. The standard with
regards to risk assessment, and developed the alert system to remind staff to order appropriate
prophylaxis. Outcome relies on staff and patient satisfaction with regards to VTE prevention.
Continuity structure on quality care applies on implementation of evidence based practice
within the organization. The administrative management is responsible to measure Performance
Improvement regularly to promote continuous improvement. Evaluation of Performance
Improvement by data collection, review compliance, monitors adverse outcomes and Incident
surveillance reporting. Surveillance is important in tracking HA-VTE. A wide-ranging
surveillance approach would collect information not only on the incidence of VTE but also
information on the prevention practices implemented. To minimize incorrect positives for VTE
in outpatient records the Quality Director requires confirmation of a diagnosis code and validated
diagnosis. Mortality attributable to pulmonary embolism can lead to missed cases because of
sudden death and collecting additional information from autopsies and death records is critical
for capturing cases and outcomes. Screening patient is important as VTE can be asymptomatic as
well asymptomatic. Because many cases of HA-VTE occur after discharge, data must be
collected from multiple settings in which VTE is diagnosed and treated (Streiff, Brady, Grant, et
al, 2014).
Conclusion. Outcome measure is vital in quality improvement initiative. In treating patient,
we would like to increase the possibility of outcomes desired by the patients and reduce the

8. FINAL PROJECT 8
possibility of undesired outcomes as hospital acquired VTE. The goal was not only to improve
the process, but also improved outcomes by reducing VTE rates .VTE is a problem of major
public health importance, with hundreds of thousands of persons affected each year. Because
nearly half of VTE cases occur during or soon after a hospital stay, there is overlap between VTE
as a public health problem and a preventable patient safety problem. Public health programs and
patient safety stakeholders, such as hospital and health-care payers, are encouraged to collaborate
to promote effective risk-stratification and VTE prevention in inpatient settings and to assess
trends in the use of risk-appropriate VTE prophylaxis for HA-VTE events and complications
(Streiff, Brady, Grant, et al, 2014).
.

9. FINAL PROJECT 9

10. FINAL PROJECT 10
30 day Re-admission Status:  no  yes ____ prior admission date:_________  NotifySocial Service
ADMISSION ASSESSMENT
 Admission Assessment completedwithin8hrs ofadmission
 Completedby RN
ADMISSION Medication Reconciliation done
 Yes
 Home meds included
CAREPLAN INITIATED AND COMPLETED BY RN 
ADVANCEDIRECTIVES ADDRESSED 
VTE PROPHYLAXIS ADDRESSED on allpatients 
 SCD and  ANTI-COAGULANT /or  DOCUMENTED CONTRAINDICATION
 Stroke  CVA  TIA
(unless contraindicationdocumented)
 VTE PROPHYLAXIS
 SCD and  ANTI-COAGULANT /or  DOCUMENTED CONTRAINDICATION
 ANTI-PLATELET ORDERED
 ASA  PLAVIX  Documentedcontraindication
 Stroke Education Done/Documented
 Immunization screeningdone
 Needs pneumovax
___Yes ___ No
 Pneumovaxadministered
_______ (date)
 Needs Flu vaccine(Oct. 1-March 31)
___Yes ___ No
 Flu vaccineadministered (Oct.1-March31)
_________ (date)
**********************************************************************************************************
ADMISSION Date: _____________________
Nurse: ____________________________
CN/ANM CheckingADMISSION Time Out: ______________________________
(Completed form to be turned in to the Director/NM)
Not Part of the Permanent Record
ADMISSION TIMEOUT
(Page 1 of 1)
*«PatientNumber»*
ACCT# «PatientNumber» MR# «MedicalRecordNumber»
«AdmitDate»
«PatientName»
«AttendingDoctorName» DOB: «BirthDate» «Gender» «Age»
«Room»-«Bed»

11. FINAL PROJECT 11
References
Donabedian, A. (1980). The definition of quality and approaches to its assessment. In
Exploration in Quality Assessment and Monitoring. Health Administration Press, 1, 95-99.
Kyrle, P.A., Rosendaal, F.R., Eichinger, S. (2010). Risk assessment for recurrent venous
thrombosis. Lancet; 376:2032–2039.
Landrigan, C.P., Parry, G. J., Bones, C.B., Hackbarth, A.D, Goldmann, D.A., Sharek,
P.J.(2010).Temporal trends in rates of patient harm resulting from medical care. New England
Journal of Medicine, 363:2124–2134.
Maynard, G., Humber, D., & Jenkins, I.(2014). Improve inpatient anticoagulant and
management of venous thromboembolism. American Society of Health-Pharmacist, 17(71), 305-
310.
McKean, S. (2010). QI lead to success in VTE prophylaxis. Healthcare Benchmarks &
Quality Improvement, 63-65.
Sollecito, W., & Johnson, J. (2013). Mclaughlin and Kaluzny’s Continuous Quality
Improvement in Health Care (4th ed.). Burlington, MA: Jones & Bartlett Learning.
Streiff, M. B., Brady, J., Grant, A. M., Grosse, S. D., Wang, B., & Popovic, T. (2014). CDC
Grand Rounds: Preventing Hospital Associated Venous Thromboembolism. Morbidity
and Mortality Weekly Report, 63(9), 190-193.