This page is for venous thromboembolism (VTE) prevention leads, clinical nurse consultants, pharmacists, medical officers, midwives and project leads improving VTE in NSW Health services.
This toolkit contains VTE-specific worked examples, templates and resources on this page to plan, run and sustain a quality improvement (QI) project.
Register your project team to gain access to the Quality Improvement Data System (QIDS). Available to NSW Health staff only.
More about the approach underpinning this toolkit
Getting started
Set a realistic timeline before you start. Lasting change usually takes 6 to 18 months to test and embed. Expect less time if you've built on earlier improvement work, or more if the change is complex or spans multiple services.
Start by identifying a specific VTE prevention problem at your facility. Common examples include:
- low VTE risk assessment completion rates on a clinical unit or ward
- inappropriate prescription of VTE prophylaxis
- low rates of patient education on VTE at discharge.
At this stage, name the problem only. Do not propose solutions yet.
Improvement projects need a problem that people are motivated to solve. Common errors at this stage include:
- selecting a problem no one is interested in
- jumping to a solution before investigating the problem
- focusing on a process that is currently unstable, for example a paper-to-electronic transition
- choosing a problem outside your team's sphere of influence.
Assess your unit's readiness for change by reviewing existing culture, communication, team practices and safety and quality concerns. If there is significant resistance, address it before proceeding.
Gather local data to support the problem you have identified using sources such as:
- ims+ (or IIMS): VTE-related incidents
- hospital acquired complications data
- annual reports, electronic data extracts and previous audits
- baseline audit: use the auditor reference guide for VTE prevention
- literature search: peer-reviewed and grey literature
- staff and patient stories: qualitative insight that complements your numbers.
You may need permission from your clinical governance unit to access certain data. You can also contact us for advice on sampling numbers and data sources.
The Institute for Healthcare Improvement recommends a baseline audit on 30 patients before implementing any change ideas.
The improvement project brief sets out the problem, why it matters, how long the work will take and the approach you will use. A strong brief is grounded in your data, takes sustainability into account, and aligns with your health service's priorities.
Use the brief to gain a project sponsor: someone in a senior position, ideally not working directly on the project, who has authority to remove barriers and secure resources. The level of seniority depends on the scope of your project (for example, a nurse unit manager versus an executive director). Communicate with your sponsor regularly.
Find a project sponsor early. Present your case for change and ask them to support the work.
A good sponsor:
- has authority to approve changes
- secures the resources the team needs
- helps remove barriers as they arise
- holds a senior role but does not work directly on the project
- believes the problem is worth solving
Communicate closely with your sponsor and provide regular updates. Your project sponsor can guide where governance sits within your health service. Operational responsibility usually integrates with existing meetings:
- Unit or ward level: integrate reporting with departmental meetings, for example surgical department meetings if your project targets the surgical ward.
- Health service, local health district or speciality health network level: integrate with the local VTE prevention working committee or equivalent.
Governance is separate from your project team. The project team carries out the interventions.
The project team should be interdisciplinary. Suggested members include:
- team leader: the voice of the project, runs meetings and coordinates the work
- QI advisor or expert (contact your clinical governance unit if unsure)
- people from all areas of the process the project will target, including senior and junior medical staff from the relevant specialties, pharmacy and nursing
- VTE clinical champions
- consumer representative, or use interviews or surveys to capture consumer perspectives.
Consider inviting colleagues likely to challenge the project. They often raise barriers and perspectives that strengthen the work.
Once the team is established, agree on the scope. Projects without a clear scope tend to grow beyond what is achievable and lose focus.
The project team's role 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.
Making improvements
This stage moves your project from problem-definition into structured testing: writing an aim, mapping the current process, generating change ideas, and testing them in small cycles.
Your aim statement captures the goal of the project. It must address the problem and must not include a solution.
A SMART aim is specific, measurable, achievable, relevant and time-bound. Remember:
- "some" or "better" is not a measure, and "soon" is not a time frame
- start small. Focus on a single unit or ward, even if the problem is widespread. Refining your approach on one unit gives you the evidence and confidence to spread the work
- avoid aim statements that suggest the desired solution, for example "implement a specific policy or process on your ward".
Examples:
- Within 12 months, 85% of adult inpatients on the medical ward will have a VTE risk assessment completed within 24 hours of admission.
- Within 6 months, 75% of maternal patients will have a VTE risk assessment completed when their clinical condition changes.
- Within 6 months, 90% of patients discharged from the Emergency Department with lower limb injuries will be assessed for their VTE risk.
Develop a flow chart of your current VTE prevention process with your project team. Map each step and decision from the time a patient enters the ward or facility until they are discharged, using standardised VTE risk assessment tools as your reference.
Use it to identify:
- the entire VTE prevention process as it currently runs
- current roles and responsibilities for each member of the team involved in a patient’s care, for example emergency department or admitting medical officer, midwives or pharmacist
- decision points, gaps, bottlenecks and variation
- where data may need to be collected to demonstrate reliability, for example documentation of risk assessment, prescribing of prophylaxis, reassessment, and patient education.
Once you have identified gaps with baseline data, brainstorm why they exist. Without understanding all the causes, solutions may focus on the wrong part of the process and the problem continues. Use the 5Ws and 1H brainstorm method against the gaps in your flow chart.
Resources
Sort the causes from your brainstorm into themes using an affinity diagram. Extend this into a driver diagram, which shows the relationship between your aim, the primary drivers (high-level factors that need to change to achieve the aim) and the secondary drivers (specific factors or interventions). Involve your QI advisor in this step.
Use the driver diagram to brainstorm change ideas for each secondary driver. Not all changes lead to improvement, so prioritise carefully. For each change idea, consider:
- how easy or hard it will be to implement (cost, time, training)
- the impact it will have on achieving the aim
- feasibility, logistics and expected outcomes.
Hard-to-implement changes should not automatically be deprioritised. Some of the hardest changes lead to the biggest improvements.
An example of Adult inpatient driver diagram with prioritised change ideas (PDF 412.9 KB)
Resources
Plan, Do, Study, Act (PDSA) cycles test changes on a small scale before scaling up. Start with one patient, one shift or one team. If the test works, expand (for example, three patients, three shifts, three teams), then continue scaling up.
PDSA cycles are designed to be rapid and sequential. Implementation only happens once small-scale tests achieve a reliable improvement.
Tips for PDSA cycles:
- test no more than three change ideas at a time
- consider testing the next change idea when you are confident in the first change idea (that is, starting to scale up the testing)
- PDSA cycles are not designed to be time consuming, and can be performed rapidly and in a staggered approach
- monitor the data and measures to track improvements (refer to Data for Improvement)
- determine which changes (or combination of change ideas) are leading to an improvement and achieving the aim
- briefly document each PDSA cycle to help understand the process and ensure all four stages are followed.
Resources
Data for improvement
When you test change ideas, collect data in real time rather than retrospectively. Quantitative data will form the bulk of your measures, but qualitative data is equally valuable.
Choose your measures
A single measure is rarely enough to determine whether improvement has happened. It is important to define the numerator and denominator and provide an operational definition for each measure to ensure data consistency.
Include one or two measures from each of three family of measures. The aim of the following measure examples is to improve prescribing of appropriate VTE prophylaxis in maternal women.
Outcome measures outline the overall result you are trying to achieve (align to your aim statement or impact goals). For a maternal VTE project, examples include:
- number of women given VTE prophylaxis appropriate to their risk level
- rate of maternal women developing VTE during their admission.
Numerator: Number of women who received VTE prophylaxis appropriate to their risk level during their post-partum admission.
Denominator: Total number of women who had their post-partum admission between Week X and Week Y.
Operational definitions: The definition of appropriate VTE prophylaxis is prescription of the recommended pharmacological/mechanical prophylaxis as per the maternal VTE risk assessment tool. Risk level is similarly determined by completing the maternal VTE risk assessment tool.
Process measures outline whether the steps in the process are working as planned. For a maternal VTE project, examples include:
- proportion of medical staff trained on appropriate prophylaxis prescribing
- proportion of nursing staff trained to use the maternal VTE risk assessment tool.
Balancing measures outline whether changes in one area are creating problems elsewhere. For a maternal VTE project, an example is the proportion of maternal women experiencing bleeding symptoms as a result of pharmacological prophylaxis.
The VTE prevention measurement strategy template (PDF 14.6 KB) includes additional examples across all three measure types, adapted to the adult inpatient and maternal settings.
Before collecting data:
- review existing baseline or historical data on the process you are improving
- collect baseline data for your chosen measures if needed
- agree as a team on who, when, where and how data will be collected
- find the most efficient way to access the data
- assign individual team members responsibility for each measure
- record data in QIDS (preferred) or a shared spreadsheet
- speak with staff and patients while testing to hear about their experience
- continue collecting data after the project to confirm gains are sustained.
Determine how much data to collect. Quality matters more than quantity. Ensure enough data is collected to determine whether the implemented changes lead to improvement. A data pool which is too small may not capture the effects of the change; conversely, a large pool of data may not possible due to time or resource constraints.
As a minimum, collect 5 to 10 data points each week (for example, 5 to 10 patients). Collect either consecutive cases or a random sample. Adjust based on the size of your service and the frequency of the problem.
Once data is collected, your team needs to interpret it to see if improvement has happened. Enter data into a spreadsheet or QIDS. QIDS builds charts directly from your data.
Run charts are line graphs showing data over time. They are an effective way to tell the project story and communicate progress to stakeholders. Annotate run charts to show when each change idea was tested and how it may have driven improvement. Your local QI advisor can help with displaying and analysing data.
To know if an improvement is real and lasting, look at patterns in your data over time. Probability-based rules help separate genuine change from random variation. On a run chart, for example, six consecutive data points above 95% signal a reliable improvement. This means the new process is followed 95% of the time.
See Safety intelligence data tools for more options to present data, including histograms and control charts.
Once the change idea (or combination of ideas) is producing reliable improvement, begin your project evaluation. Document the impact of the changes, what worked and what did not, and the lessons that will shape the next phase of work.
Resources
Communicating change
It is important to communicate the change your improvement project will bring about by engaging relevant stakeholders and creating awareness through engagement activities.
A stakeholder engagement plan sets out how you will communicate with patients, carers, clinicians, non-clinical staff and executives. It specifies the frequency, type and content of communications that build and maintain engagement at every level.
Download stakeholder engagement plan - guide and template (PDF 34.1 KB)
Each stakeholder group has different needs and motivations. Useful activities for VTE prevention projects include:
- using hospital-wide channels such as newsletters, the intranet and memos
- using local nursing, medical and pharmacy champions, and VTE prevention leads, to advocate for improvement
- creating a ward display board or handing out educational fact sheets and project data
- setting a standing agenda item or short presentation at regular meetings
- using double-staffing time or staff meetings for short, regular updates
- creating posters, lanyards and computer screensavers
- holding a project launch or workshop, or integrating engagement into existing events such as medication safety forums or Grand Rounds
- running awareness campaigns to coincide with World Thrombosis Day, World Patient Safety Day or Patient Safety Awareness Week
- running a quiz, creating social media posts or sending email updates
- distributing information to general practitioners or visiting medical officers in rural and regional areas.
Providing education
Developing and delivering education is a fundamental component to ensuring project success. Education and training will need to be delivered to a variety of stakeholder groups at numerous points throughout the project lifecycle.
Two online courses are available through My Health Learning:
- Adult inpatient VTE risk assessment tool: course code 212082420
- Maternal VTE risk assessment tool: course code 351903916
For clinical training resources by patient group, see the risk assessment page.
When planning education:
- share delivery across your team rather than carrying it alone
- engage your audience with an interactive poll or pre and post-quiz to check perception and knowledge change
- include a recent VTE-related patient story from your health service to build engagement
- invite a respected local clinical champion to speak to the targeted unit or ward
- ask attendees to work through VTE case studies
- run short, frequent sessions to lift attendance, and plan how staff working nights or weekends will receive education
- collect feedback after each session to improve future sessions
- keep an attendance record.
Sustain and spread
Once a change has produced a measurable improvement, the final step is to embed it into everyday practice and spread it across the service.
Develop a sustainability plan early, not at the end of the project. Involve your QI advisor.
Embedding improvement into practice usually involves:
- standardisation: work processes, roles and responsibilities, documentation
- education: built into routine training for all staff
- ongoing measurement: collected and reviewed regularly.
Sustain measurement over time
Embed data collection into standard practice in your ward or health service. Include staff and patient stories and other feedback to track sustainability.
Once testing ends, you can collect data less often. For example, move from monthly to three-monthly collection, then to six-monthly. Make sure your project sponsor, health service executive or senior management can see this data.
If the improvement is not sustained
If compliance drops at any point, step back in. You may need to resume more frequent measurement to understand why and repeat your PDSA cycles to get the change back on track.
Useful frameworks include the National Health Service England Sustainability Model.
Spreading means actively rolling the change out to other wards, units, services or districts. What works in one setting may not work in another. Revisit the improvement process and adapt for local context, for example when moving from a paper to an electronic environment.
The Institute for Healthcare Improvement’s seven spreadly sins (PDF 424.9 KB) sets out practical pitfalls to avoid.
Once an improvement is sustained and spread, the health service is responsible for ongoing monitoring. Build measures into your performance indicators and complete audits at a frequency determined locally.
As technology evolves and processes change (for example, moving to electronic systems), revisit the process to make sure improvements remain embedded.