Evan Benjamin, MD, FACP, Vice President, Healthcare Quality, Baystate Health
Jan Fitzgerald, MS, RN, Director, Quality and Medical Management, Division of Healthcare Quality
Gary Kanter, MD, Associate Medical Director, Division of Healthcare Quality and Medical Director, Pre-Admission Evaluation Unit
Michael Rothberg, MD, Associate Medical Director, Division of Healthcare Quality
Susanna Hall, MBA, RN, Director, Hospital Case Management, Division of Healthcare Quality

To decrease the rate of post-operative myocardial infarction (MI) and VTE (DVT/PE) in post-operative patients by 50 percent within 12 months (October 2004 to October 2005).

• Rate of post-operative VTE events per quarter
• Rate of post-operative myocardial infarctions per quarter

• Development of standardized guidelines and treatment recommendations for VTE prophylaxis and perioperative beta blocker use
• Implemented use of a pre/intra/post-op beta blocker protocol
• Developed pre-printed/CPOE orders based on the ACCP
• Implemented daily rounds for HCMs to review VTE therapy
• Global education to all clinician providing care to at risk population
• Pre-admission evaluation screening by anesthesiologist
• CPOE screening
• Reported monthly measure data to the SCIP/Surgery Anesthesia/Surgery PI teams
• Real time review of risk of post-op MI and VTE events
• Review for appropriateness of therapy (pre-op screening, immediate pre-op review, post-op screening by RNs prompting physicians and implementing standing protocols)
• Secondary coding review to prompt physicians to determine “actual post-operative events” instead of “on admissions” events
• Case review, papers published
• Ongoing rates reported to Surgical Services adopted as a program monitor
• Case review by clinicians for potentially preventability with one-on-one communication to review any overuse, underuse or misuse

Implementing procedures and evidence-based care recommendations can be a slow process. Our continued efforts and focus on these two safety practices have resulted in a reduction in post-op DVT/PE (from 1.09 to 0.47 percent) and MI (from 0.53 to 0.31) as a result of our multi-pronged team interventions. 

• Implementing procedures for beta blocker screening and real time VTE review have been significant in changing how we prepare patients for operative procedures. Physician support has been adopting these process.
• Involve the right people. It is important for the “players” or those directly involved in the process to have a voice. This helps in identifying problem areas and to more quickly obtain buy-in.
• Use rapid cycles of change. This eliminates wasted time in researching, planning, developing, education, implementing, etc. without knowing if the process truly works. 
• Make the process as simple as possible. Make the “Right thing the easy thing”. This helps to make it a win-win situation for both the patient and staff.
• Share the success. Print graphs, make posters, buy pizza, take pictures, etc. to celebrate your accomplishments.
• Don’t be afraid of failure. You can learn as much from a failed test as you can from a successful one.
• Don’t reinvent the wheel. If another organization has used a strategy, idea or form that works, adopt it.
• Communicate, communicate, communicate! Get the word out to everyone. It helps to use different vehicles to communicate: meetings, hospital publications, flyers, etc.
• Gain a strong commitment from senior leadership. Their support is crucial. When they round to different units, have them ask the staff about their role in reducing events, what they have identified that could cause harm, or what they have to do in their jobs to prevent harm. 

Evan M Benjamin, MD, Vice President, Healthcare Quality
Baystate Medical Center
evan.benjamin@bhs.org

[Storyboard presentation at IHI's National Forum, December 2005]