Hospital-acquired VTE is a leading cause of preventable death and has significant impact on quality across hospital systems related to both patient care and financial/reputational programs. Compared to other academic medical centers, in addition to other entities within MedStar Health, MedStar Georgetown University Hospital had a significant opportunity to reduce hospital-acquired VTE events​​. The President’s Goal for fiscal year 2024 focused on reducing the hospital acquired comprehensive VTE rate by 30%. A multidisciplinary project team was assembled and identified ten key areas of focus. By targeting VTE reduction from all angles, MedStar Georgetown achieved a significant reduction in VTE.
Problem: Engaging leadership and strategy to yield a 30% reduction in our institution’s hospital acquired comprehensive VTE Rate by the end of FY2024.
Measurement: A fishbone diagram was utilized to identify contributing factors. A control chart was used to track our comprehensive VTE rate over time.
Analysis: We utilized SMART Methodology (Scope, Measure, Analyze, Rethink, Track) as our continuous improvement framework. We tracked our comprehensive hospital acquired VTE rate using data from Vizient.
Implementation: A multidisciplinary project team created action items targeting 10 different areas of focus. A major barrier encountered was competing priorities. This was mitigated by executive support and prioritization. This strategy can be replicated by other healthcare organizations to achieve similar positive results.
Results/Discussion: We have seen a year-to-date reduction of 69.8% in our comprehensive VTE rate. The utilization of SMART methodology and project management principles were critical to our success. Our plan for sustainment has been built into each of the solutions generated by the project.
