This document summarizes a quality improvement project to increase appropriate DVT prophylaxis for women undergoing cesarean delivery at Texas Health Presbyterian Dallas. The team developed educational tools, provided training to physicians, nurses and staff, and had frontline nurses perform monthly audits. Through these efforts, documentation compliance increased and the rate of appropriate DVT prophylaxis rose by 10% above the original baseline of 80%. The project utilized Lean Six Sigma tools like an Ishikawa diagram to identify challenges and plan improvements to standardize the work flow and documentation of DVT prophylaxis for cesarean patients.

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TEXAS HEALTH PRESBYTERIAN DALLAS08/04/15 1
TEXAS HEALTH PRESBYTERIAN DALLAS
O.C.E
Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery
Quality Improvement
Jen Caldwell & Kathy Moon

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TEXAS 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?)
1. Future State or Solutions
2. Results
– Final results – photo, chart, process map, etc
1. PDSA / Summary Slide
2. LSS Questionaire
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TEXAS HEALTH PRESBYTERIAN DALLAS
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

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TEXAS 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

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TEXAS HEALTH PRESBYTERIAN DALLAS
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

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TEXAS HEALTH PRESBYTERIAN DALLAS
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
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TEXAS HEALTH PRESBYTERIAN DALLAS
Analysis of Cesarean Section Patients
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TEXAS HEALTH PRESBYTERIAN DALLAS
Solutions
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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

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TEXAS HEALTH PRESBYTERIAN DALLAS
Results
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TEXAS HEALTH PRESBYTERIAN DALLAS
Tipsheet for documentation of SCDs
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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.

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TEXAS HEALTH PRESBYTERIAN DALLAS 11
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).
Tipsheet for documentation of SCDs

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Tipsheet for documentation of SCDs
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.

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TEXAS HEALTH PRESBYTERIAN DALLAS 13
Tipsheet for documentation of SCDs
• 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.

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TEXAS HEALTH PRESBYTERIAN DALLAS08/04/15 14
TEXAS HEALTH PRESBYTERIAN DALLAS 14
DVT Prophylaxis in Women Undergoing Cesarean Delivery
Jen Caldwell, Kathy Moon, Keith Turner, Jamie Caldwell, Dr. Eugene Hunt, LaVona Wilkes,
Theresa Lobmeyer, Carol Gentry, Patti Marks, Mary Collins
State Date: 1/27/2013
Problem 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.

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TEXAS HEALTH PRESBYTERIAN DALLAS
Lean Six Sigma Belt Questionnaire
for 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%.