Getting started

Prior to starting, it is important to determine a realistic timeline for the improvement work lasting changes will often require an investment of time. As a guide, it can take 6 to 18 months to test and implement a lasting change using improvement science methodology.

This timeline may be shorter if previous improvement efforts or investments have been made and may be longer if the change is complex and/or involves different services and departments.

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in Australia with more than 14,000 Australians diagnosed with a VTE each year, and more than 5,000 cases resulting in death¹. Hospitalisation has been found to be a major risk factor in the development of VTE and evidence suggests that VTE is highly preventable. Studies have found 30-65% of VTE cases to be preventable if appropriate provision of prophylaxis is provided^2-3, which relies on patients receiving timely and appropriate risk assessment.

To undertake a VTE Prevention improvement project, you must identify a problem that you want to improve, for example:

• Poor VTE risk assessment completion rates on a clinical unit/ward
• Inappropriate prescription of VTE prophylaxis
• Low rates of patient education on VTE at discharge

At this stage of the project, it is about identifying the problem you aim to improve NOT brainstorming solutions. When determining the focus of an improvement project, some common errors include:

• Selecting a problem no one is interested in
• Implementing a solution rather than investigating a problem
• Focusing on a process that is currently in transition or unstable, for example, manual to electronic process
• Selecting a problem that is beyond your capability to change or outside your sphere of influence.

All improvement requires change. However, change is not always welcomed or accepted by individuals or teams, even when it is improvement focused. Improvement projects can often struggle to gain momentum if there is considerable resistance from those who will be impacted most by changes.

Assessment of the current unit/ward context is essential to clearly establish the readiness for change. The assessment should investigate the existing culture, communication and team practices, and safety and quality concerns. If there is an overall lack of enthusiasm and a resistance to change, it is vital this is addressed before proceeding further with the improvement project. Find more information on the CEC Safety Culture webpage.

Data will assist in identifying the problem and build the evidence base about why this is an important problem to focus on. Seek guidance from your Clinical Governance Unit or the CEC to identify appropriate sampling numbers and data sources.

Existing data: You can examine your health service's VTE related data from sources such as your incident management system (e.g. ims+, IIMS), Hospital Acquired Complications (HAC) data, annual reports, electronic data extracts, previous audits etc. It may also be useful to speak with medical records about the cost of VTE related complications.

Note that you may require permission from your clinical governance unit to access certain data.

Baseline: Completing a baseline audit is also an effective way to identify the problem e.g. the CEC QARS VTE Prevention Audit – Auditor Reference Guide can assist in data collection.

Note: Prior to implementing any change ideas (later in the quality improvement process), the Institute for Healthcare Improvement suggests that you conduct a baseline audit on 30 patients for the measure you aim to improve.

Literature search: Further information can be gathered by conducting a literature or grey search.

Patient and Staff Stories: It is worthwhile collecting anecdotal evidence about how VTE has impacted patient hospital stays. These stories help us to understand different perspectives of the health care given or received and can shed light on different areas for improvement.

Further resources to gather baseline data can be found on the Improving VTE Prevention Processes page.

An improvement project brief is essentially a document that outlines your improvement project and is key to gaining the support of your health service. It should include what the problem is, why is it important to address, how long the anticipated initiative will take and the approach you will use to achieve an improvement. A strong case for change should be founded on the supporting data you have collected, take into consideration how the improvement will be sustained and align with your health service's priorities.

• Improvement Project Brief Template - VTE Prevention

It is strongly recommended that you engage with your Clinical Governance Unit to seek support for and during your improvement project. Your Clinical Governance Unit can connect you with local quality improvement experts or groups with a vested interest in improving VTE outcomes e.g. Local/district VTE working group, clinical champions, VTE prevention leads etc.

You may also choose to reach out to colleagues in other health services to find out how they approached their improvement work, including their successes and learnings.

Use your improvement project brief to gain a project sponsor. The role of the project sponsor is to provide support and guidance to the project team, receive regular reports on progress and help remove barriers when needed. They should believe that the problem is worth solving, have authority to make changes and ensure that appropriate resources are provided.

Ideally, your project sponsor is someone who does not work directly on the improvement project but is in a senior position. The level of seniority of the project sponsor will depend on the scope of your improvement project (e.g. Nurse Unit Manager versus an Executive Director). Ideally you should communicate closely with the project sponsor and provide regular updates to them on the progress of your project.

Ask your project sponsor to provide guidance on where the governance for your improvement project should sit within your health service. This will ensure there is operational responsibility for your VTE Prevention improvement project and a channel to report back on how it is progressing. For example:

At unit/ward level: If your project aims to improve VTE outcomes on the surgical ward, you could integrate project reporting with existing surgical department meetings.

At health service/LHD/SHN level: If there is intention for your project to be scaled across your facility, reporting could be integrated with the local VTE Prevention working committee.

Note that who you report your project progress to is not the same as who is part of your project team. Your project team will consist of members who carry out the project interventions.

• Team leader
• Quality improvement advisor/expert (contact your clinical governance unit if unsure)
• People from all areas of the process that the improvement project will target e.g. senior and/or junior staff from the main medical specialties on the ward/unit your project will take place, pharmacy, nursing, VTE clinical champions
• Consumer representative (or interview/survey consumers)
• Consider inviting colleagues who are likely to challenge your project. They can often raise different perspectives or barriers that you may not have considered.

The team leader role is essential and they will organise and lead the team meetings, ensure delegation of responsibilities and be the 'voice' for the improvement project.

As the team leader, it is essential to assemble a dedicated team who are also committed to actively supporting the improvement project. Improvement projects often fall down when team members are unable to sustain interest or participation in the improvement project, leaving the team leader to carry the improvement project.

The role of the project team includes:

• Evaluating current VTE prevention processes
• Identifying and enlisting clinical champions
• Establishing general goals
• Developing, implementing and evaluating VTE prevention improvement strategies
• Disseminating results and findings.

Once the project team has been established, it is important to make sure everyone is on the same page regarding the problem the improvement project is targeting and what is IN and OUT of SCOPE. Without a well-defined scope, improvement projects tend to grow beyond what is achievable, lose focus of the problem, and fail.

1. Access Economics. The burden of venous thromboembolism in Australia: Report by Access Economics Pty Limited for The Australia and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism, May 2008. Accessed 1 April 2014.
2. Bergqvist D, Geerts WH, Pineo GF, et al., 2008, 'Prevention of venous thromboembolism'. Chest, 133:6 suppl 381S453S, pp. 381-453
3. McDonald KM, Shojania KG, Wachter RM, et al., 2004 'Closing the quality gap: a critical analysis of quality improvement strategies (Volume 1 – Series Overview and Methodology)'. Technical Review 9 (Contract No. 290-02-0017 to the Stanford University – University of California, San Francisco, Evidence-based Practice Center).