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CS&E Educational Program

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Program Description: The Science of Process Management

Quality Improvement is the science of process management. Health-care delivery is a complex system made up of thousands of interlinked, and therefore interdependent, processes. Since

  • all work is a process
  • all processes vary
  • variation is an indication of waste

We must learn to:

  • identify
  • measure and
  • minimize the variation in all our health-care processes to maximize the quality of the health care we deliver

Waste takes several forms in health care:

  • over-treating
  • under-treating
  • mistreating
  • delays
  • close-calls and errors

In “Fourth Generation Management” (McGraw-Hill, 1994), Brian L. Joiner, a protégé of W. Edwards Deming, discusses in detail various aspects of managing and improving organizations using the process paradigm. In “Measuring Quality Improvement in Healthcare” (Quality Resources, 1995), Raymond G. Carey and Robert C. Lloyd present a methodology for quantitatively measuring variation and tracking the effects of process changes.

Snippet From Session 2 Graduation Class 2006

An ounce of prevention is worth a pound of cure.

Screening for VTE before a clot occurs

Project: 

To develop a screening tool to measure a patient’s risk for venous thromboembolism (VTE)

Outcome:  

  • Used tool in a liquid tumor unit
  • Provided continuing education classes on VTE to nursing staff
  • During 2005, nearly one million people in the United States developed one or more blood clots in one of the deep veins* of their legs, (deep vein thrombosis, or DVT)
  • Almost one-third of cases ended in death from complications
  • Both DVT and pulmonary embolism (PE) are examples of venous thromboembolism, or VTE

CS&E Training Course graduates, Shu-Wei Gao, M.D., assistant professor, General Internal Medicine, and Victoria Hawkins, Dr.P.H., nurse specialist, Practice Outcomes, present a cogent argument for preventing blood clots in all medically eligible patients at MD Anderson. Hawkins cautions that the immobility during the hospital stay, such as being confined to a bed or in a chair for 50% of the time or more, is one of the most important risk factors for developing a VTE. “A patient with malignancy and a VTE at the same time is three times more likely to die within six months than a patient with malignancy alone,” says Hawkins. “We want to make sure that patients receive appropriate prevention to avoid the formation of dangerous blood clots.”

Other known conditions that can put patients at risk for VTE include

  • History of a previous VTE
  • Stroke 
  • Heart failure
  • Emphysema
  • Concurrent infection
  • Advanced age
  • Conditions such as Factor Leiden V 
  • Obesity  
  • Varicose veins

In January 2006, the team identified the VTE risk factors for this patient population and measured VTE prevention measures on the unit. Each patient was screened twice for VTE risk using the new VTE risk assessment-screening tool: once by the admitting nurse on the unit and once by the APN assigned to that patient. The patients were screened twice in order to test the inter-rater reliability of the screening tool. Additionally, the team determined that VTE prevention measures such as anti-coagulation medications were used 4.5% of the time before the project began and increased to 15% of the time by the end of the one-month project. 

The CS&E project team reported it met the outcome of its aim statement, “To establish an evidence-based screening process for risk of VTE on G9 and to identify the risk factors and practice patterns for 90% or more of its patient population by February 2006.”

Financial findings

To address financial concerns, the team worked with the business office to hammer out the estimated costs to an MD Anderson patient. What they found out was eye-opening: a difference of almost 20 fold between treatment and prevention:

Treatment for VTE: Average per admission = $15,926 

Prevention of VTE: Average per admission = $815

Next steps

On April 10, 2006, the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) announced the recommendations of the Technical Advisory Panel for Venous Thromboembolism (VTE). Among them and posted on the JCAHO Web site is that a VTE risk assessment should be performed and documented in the medical record for all patients within 24 hours of admission to the hospital, and that appropriate preventive measures should begin within 24 hours. An alpha test will be conducted during the summer of 2006 in a limited number of hospitals with the objectives of assessing face validity and data collection issues followed by a pilot test in early 2007.

Gao and Hawkins say that through their CS&E project they’ve demonstrated that VTE prevention measures can be improved through risk assessment. “With further educational efforts and good preventive practices,” Hawkins says, “we can greatly reduce the incidence of VTE in the years to come.”

*Study presented at the American Society of Hematology’s 2005 annual convention.


© 2014 The University of Texas MD Anderson Cancer Center