Doctors in Lab | Virginia Mason Institute

Case Study: Achieving Zero Preventable Hospital-Acquired Venous Thromboembolism Events

Virginia Mason Institute

Saving lives, eliminating defects and improving processes

The problem

Venous thromboembolism (VTE) is the third most common cardiovascular illness1 — and the most common preventable cause of hospital-related death.2 In the United States alone, approximately 1 million patients experience VTE events. Nearly two-thirds of these events occur because of hospitalization, resulting in approximately 300,000 deaths.3

In just one year, a 300-bed hospital that does not engage in systematically preventing VTE can experience 150 cases of hospital-acquired VTE — with up to 75 of those cases considered preventable. Even worse, about 5 of these patients will die from pulmonary embolism (PE). Financially, each hospital-acquired VTE adds an inpatient cost of $10,000, and each PE adds $20,000.4

Despite abundant evidence that methods to prevent hospital-acquired VTE are effective and safe, prophylaxis is underutilized, with only 30 to 50 percent of eligible patients receiving it.5

“We reinforce the message that VTE results in preventable deaths and we need to do our part to keep patients safe.”

Rowena Browman, MN, RN

Virginia Mason’s journey to improve patient care

In 2009, a Virginia Mason team set out on a journey to prevent all incidents of hospital-acquired VTE in the critical care (intensive care) unit. Using innovative strategies and the lean tools of the Virginia Mason Production System® (VMPS), the team of leaders and providers were determined to provide specific, evidence-based VTE prophylaxis for every patient — from hospital admission to discharge — that is optimal to the patient’s changing clinical condition and that achieves zero incidents of potentially preventable hospital-acquired VTE.

At the outset, Virginia Mason created a VTE therapeutics committee composed of a multidisciplinary team of representatives from medicine, nursing, quality assurance, pharmacy, information systems and patient safety. These representatives were chosen to show respect to those whose work would undergo profound changes, to obtain experienced feedback, to gain commitment, to boost early adoption of interventions and to perfect the usability of the interventions. Sponsored by two Virginia Mason physician executives, the committee began meeting every month in 2009 to discuss successes, failures, quality metrics and new ideas to improve the daily work. Early on, the committee defined the process for reporting and taking action on the six CMS measures related to VTE. They began with a focus on VTE-2 (intensive care unit venous thromboembolism prophylaxis), so they could create and refine their best practices in a specific unit before spreading to more units.

Set MeasureMeasure Short Name
VTE – 1Venous Thromboembolism Prophylaxis
VTE – 2Intensive Care Unit Venous Thromboembolism Prophylaxis
VTE – 3Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
VTE – 4Platelet Monitoring on Unfractionated Heparin
VTE – 5Venous Thromboembolism Warfarin Therapy Discharge Instructions
VTE – 6Hospital-Acquired Potentially Preventable Venous Thromboembolism

They also defined the reporting and action processes for any patients readmitted with a new VTE within 30 days of discharge, and they identified who should be on point to coordinate actions taken for defects and overall reporting standards. In what would be one of the most significant moves, the committee members formed a work team of more than 50 employees who would be engaged in implementing the VTE work.

Notable committee and work team achievements

The VTE committee and work team collaborated in numerous ways to chip away at the barriers preventing them from reaching their goal of zero defects. They held kaizen events (interactive and intensive improvement events of one, two or three days with a small group of employees regularly involved in the work) to carefully observe the processes surrounding critical care unit (CCU) care, and they noted areas of concern, used root-cause analysis to uncover the causes, tried out new ideas, tested them thoroughly, trained employees and rolled out the new processes to be used with patients. Each of these kaizen events was made up of employees deeply involved in the work, and each of these workers was called upon to uncover problems and devise and implement new solutions. Here are three of the many projects the committee and work team undertook:

Mistake-proofing with a new andon board

To achieve the ultimate goal of zero incidents of hospital-acquired VTE, the committee members focused their efforts on rolling out the VTE Clinical Andon Board, which was inspired by one of Toyota’s most famous quality-control methods, the andon. At Toyota, the andon is a system that frontline workers use to alert management, maintenance and other workers when they discover a problem with quality. At Virginia Mason, the VTE andon features an electronic board that uses color cues — red, yellow and green — to let viewers identify patients’ VTE prophylaxis status at a glance. The patient name appears in red when no VTE prophylaxis (VTEP) has been ordered, when the reason for VTEP has not been documented or when sequential compression device (SCD) documentation is lacking. The patient name is yellow when the reason for VTEP has been documented, SCDs have been ordered and documented, or the appropriate medication has not been given. The patient name is green only if pharmacological prophylaxis has been ordered and administered.

Why use an andon board? “We have to get the care right while the patient is here,” says Barry Aaronson, MD, a hospitalist and data informatics specialist. “Also, providers learn best from real-time feedback. It’s not the same when they see data weeks or months down the road — because at that distance they don’t remember the patient or the circumstance surrounding the care. But when providers see the red, yellow and green lights in real time, they’re grateful. They’re learning.”

And providers aren’t the only ones who see the board — patients and families see it too. “Transparency is important at Virginia Mason,” says Niloofar Alikashani, PharmD, RPh. “Any family member can ask any staff member why a patient’s name is in red. It helps keep everyone accountable.”

Aaronson says the andon board works because, “it’s in your face.” He’s also quick to say that staff need to know they can trust that the real-time information they’re seeing is accurate. “There can be no false alarms,” he says. “When every alarm is real, providers know they need to act on every red and yellow light.” Ongoing feedback and responsiveness to that feedback are essential, too, for ensuring that the andon board is always the best it can be.

Increasing patient adherence with an updated prophylaxis pamphlet

To tackle the problem of patient refusal to accept prophylactic measures, the team knew it had to educate patients and their families in a manner that clearly communicated the benefits and risks of assenting to prophylaxis and refusing it. The patient-education pamphlet they’d been using had not been an effective tool, and the team met with providers and patients — using the tools of experience-based design — to find out why. The team discovered that the pamphlet did not use an appropriate level of language, did not use appropriate images and was not readily available to providers when a patient refused prophylaxis. After consulting with the director of education and health literacy, the team created a new pamphlet to fix the problems and tested it with physicians, nurses, pharmacists and patients. Now, when a patient refuses prophylaxis after reviewing the pamphlet, a provider is notified to follow up with the patient.

Eliminating delivery discordance to improve the ordering and delivery steps of prophylaxis

In 2010, data gathered during VTE safety rounds showed that 7.3% of patients refused heparin, a drug important to their safety. More troubling, only 37% were wearing SCDs in a functional manner — that is, the sleeves might be on but the motor off.6 In preparation for a kaizen event, the team found that the average percentage of at-risk hospitalized patients with VTE prophylaxis ordered was 94%, yet patients received only 85.6% of prophylaxis ordered. Additionally, SCDs were not on the patient 52% of the time. The ordered SCDs were observed on windowsills, on the edge of the bed or not in the room at all.7

To reduce delivery discordance, the team scheduled a kaizen event using the principles of 5S (sort, simplify, sweep, standardize, self-discipline), as well as setup reduction and mistake-proofing.

At 90 days after implementation, the data showed a reduction in the lead time from the time the provider ordered an SCD to the time an SCD sleeve was applied — from 5 hours, 51 minutes to 2 hours, 54 minutes. The team also reduced the percentage of time the patients did not have SCDs in place within four hours of physician order from 75% to 0%. In another win, they reduced the percentage of time SCD sleeves were not applied on the patient within 1 hour of equipment arrival from 75% to 0%.8


In August 2015, with the help of the VTE Clinical Andon Board, innovative improvement work and motivated committee and work team members who have met monthly since 2009, Virginia Mason reached a milestone. The organization achieved 100% compliance with the CMS measures for VTE prophylaxis for intensive care patients — for 25 consecutive months. The work continues. Today the committee and work team are spreading the work from the CCU to the rest of the hospital.9

Key elements that have made it successful

Leadership buy-in. Before the VTE project, Aaronson built an electronic dashboard for ventilator-assisted pneumonia at another organization. But providers didn’t pay attention to the dashboard because it wasn’t part of their daily routine. At Virginia Mason, when he proposed the idea of a dashboard to reduce hospital-acquired VTE, the leaders told him they would support his project if he and his team used Virginia Mason’s lean tools to track progress and engage staff. From then on, from the executive level to the director level, the leaders said consistently to providers, during rounding and at meetings: “This project is important and we expect you to do it.” They made sure that providers helped create the standard work, tested it, received training and made it part of their daily processes.

Staff buy-in. Not only are staff involved in creating the standard work, but they’re also expected to speak up if they see safety gaps and to bring ideas for improvement to their daily huddles. When a staff member voices an idea to improve the andon board, for example, Aaronson and other team members thank the employee and evaluate the idea. If the idea will likely improve patient safety, Aaronson tests the idea and, if appropriate, updates the next version of the andon board.

It’s also crucial to identify the roles of staff in the process. “Staff who understand their roles in the improvement efforts develop a new sense of purpose when they go to work — a sense of connecting to the goals of the organization and the health of the patients they care for,” says Ellen Noel, MN, RN, a clinical nurse specialist who worked for two years on the VTE therapeutics committee before joining Virginia Mason Institute’s faculty. “Engaged staff members gather the data, share it and use it in their daily work to accelerate the improvement. This kind of engagement happens all over Virginia Mason, and for many departments, an andon board is not necessary. But making the work visible is key.”

Team meetings that engage members. For one thing, the multidisciplinary team members take turns addressing the agenda’s different topics. Additionally, Alikashani says, “The meetings aren’t boring. We use real patient cases to prove that the work they are doing every day is necessary. Using the six CMS measures, we call out all the defects that took place in the past month and ask, ‘What went wrong?’ We ask them to work as a team to analyze them, generate ideas and solve them collectively. After that we determine who will provide feedback and training to the employees who were involved in the cases so the defects won’t happen again.”

Recognition. It’s important to thank workers who point out problems, come up with ideas to make processes safer and more efficient, and implement the new ideas. And for every month that no hospital-acquired VTE occurs, the team is notified and congratulated for working together to realize their remarkable goal. Alikashani has also applied for, and won, two awards for the committee and work team — Virginia Mason’s annual Mary McClinton patient safety award, the organization’s most prestigious award, and the Qualis Health Award of Excellence in Healthcare Quality, which is given to organizations “that have transformed healthcare delivery for their communities — making a real difference for their patients and their families.”10

Training. To be sure everyone is properly trained and aware of the importance of twice-daily monitoring, VTE is addressed every day in rounds. In addition, as Lisa Chamberlain, PharmD, notes: “There is a skills map for all pharmacists — it is posted in the pharmacy, and it allows us to know who has been trained or needs to be trained.”

Spreading the work

In 2014 the team spread the work to the rest of the hospital, taking on the challenge of providing defect-free care in accordance with VTE-1, the first CMS measure, for VTE outside the CCU. For the rollout to succeed, they realized they didn’t have enough pharmacists to own the work outside of the CCU, so they turned to the charge nurses, who took on management of the andon board. Today, when a charge nurse sees a red indicator that relates to nursing, he or she follows up with the assigned nurse in flow. If the indicator relates to physicians, the charge nurse pages the appropriate physician and indicates the necessary action. The nurses also educate the patients and families about the board and the ways prophylaxis can help prevent hospital-acquired VTE.

By August 2015 the defects had dropped so significantly that the team’s work outside of the CCU, for VTE-1, had resulted in a 12-month compliance rate of 97.7%. For VTE-6 (hospital-acquired potentially preventable venous thromboembolism), the number is now 2%. “Of course there’s still a goal to get to 100% for VTE-1 and to 0% for VTE-6,” says Alikashani, who oversees the work outside the CCU with Aaronson and other team members. “We’ve got to keep going at it.”

How did they get the nurses engaged to take ownership outside the CCU? Rowena Browman, MN, RN, director of cardiac telemetry and acute care of the elderly, says that from the start the message has been clear: “We reinforce the message that VTE results in preventable deaths and we need to do our part to keep patients safe.”

Noel says that Aaronson continually keeps the goal alive. “Barry is a visionary leader and is very passionate about the team’s work,” she says. “When the numbers hit 97% and then 99%, another leader might have chosen to let it go by the wayside because the numbers were so good, but Barry knew it was possible to do better and has stuck to the vision.”

hospital, acquired, events, healthcare, lean

Sustaining the work

People ask Aaronson how the team manages to sustain defect-free VTE prevention. He cites three things: sticking to your vision, doing the work for your patients and never letting it go. First, he says, the vision at Virginia Mason is to be a quality leader in health care — and preventing hospital-acquired VTE is an essential component in making all CCU patients safe.

Second, leaders and staff at Virginia Mason are part of an ingrained culture that puts patients first in all that they do. They know that every process they undertake needs to have value, first and foremost, for the patient. They also understand that their patients want defect-free care month after month, so they’re motivated to keep that number at 100%.

Third, leaders can never assume that the defect-free process has been perfected and will continue on its own. The stakes for patients are simply too high. “If you want the train to keep going,” he says, “you have to keep shoveling the coal.”


1. Goldhaber SZ, Bounameaux H. Pulmonary embolism and deep vein thrombosisLancet. May 12, 2012; 379(9828): 1835-46. doi: 10.1016/S0140-6736(11)61904-1.
2. Maynard G, Stein J. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement. Prepared by the Society of Hospital Medicine. AHRQ Publication No. 08-0075. Rockville, MD: Agency for Healthcare Research and Quality. August 2008.
3. Ozaki A, Bartholomew J. Venous thromboembolism (deep-vein thrombosis and pulmonary embolism). Cleveland Clinic website. Accessed September 8, 2015.
4. Maynard G, Stein J. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement.
5. Maynard G, Morris T, Jenkins I, Stone S, Lee J, Renvall M, et al. Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment modelJ Hosp Med. 2010; 5:10-18.
6. Virginia Mason data on file.
7. Virginia Mason data on file.
8. Virginia Mason data on file.
9. Virginia Mason data on file.
10. Qualis Health. 2015 Qualis Health Washington Quality Award winners announced. Qualis Health website. May 7, 2015. Accessed September 21, 2015.

Similar resources

Stay connected

Sign up for our monthly emails to stay up to date with our latest news, resources, case studies, events and more.

Your information will not be shared. Learn more about our privacy policy here.