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J Nurs Care Qual Vol. 30, No. 3, pp. 226–232 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Health Care Systems Redesign Project to Improve Dysphagia Screening Virginia S. Daggett, PhD, RN; Heather Woodward-Hagg, PhD; Teresa M. Damush, PhD; Laurie Plue, MA; Scott Russell, BS; George Allen; Linda S. Williams, MD; Neale R. Chumbler, PhD; Dawn M. Bravata, MD The purpose of this project was to improve dysphagia-screening processes in a tertiary Veterans Affairs Medical Center. The dysphagia-screening tool was redesigned on the basis of frontline clinician feedback, clinical guidelines, user satisfaction, and multidisciplinary expertise. The revised tool triggered a speech-language consult for positive screens and demonstrated higher scores in user satisfaction and task efficiency. Systems redesign processes were effective for redesigning the tool and implementing practice changes with clinicians involved in dysphagia screening. Key words: dysphagia, quality improvement, screening, systems redesign, veterans
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YSPHAGIA (or difficulty swallowing) is common in the United States, with the prevalence rate varying depending on the Author Affiliations: Department of Veterans Affairs VISN 11 Center for Applied Systems Engineering (VA-CASE) (Drs Daggett and Woodward-Hagg), Department of Veterans Affairs Research & Development (R&D) Service (Dr Daggett), Department of Veterans Affairs Systems Redesign Service (Dr Woodward-Hagg), and Department of Veterans Affairs Health Services Research & Development (HSR&D) (Center for Health Information and Communication) (Drs Damush, Williams, and Bravata and Ms Plue and Mr Russell), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of General Internal Medicine and Geriatrics (Dr Damush), Department of Neurology (Drs Williams and Bravata), and Department of Internal Medicine (Dr Bravata), Indiana University School of Medicine; VA HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana (Drs Damush, Williams, and Bravata); Indiana University Center for Aging Research, Indianapolis, Indiana (Dr Damush); Regenstrief Institute, Indianapolis, Indiana (Drs Damush, Williams, and Bravata); Department of Veterans Affairs, Office of Informatics and Analytics, Analytics and Business Intelligence, Washington, DC (Mr Allen); and Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia (Dr Chumbler).
concomitant medical disorders. A populationbased study reported the overall prevalence of dysphagia to be 14% with 23% in an This study was internally supported by Department of Veterans Affairs Stroke QUERI 03-158, Indianapolis, Indiana. This work was performed at the Department of Veterans Affairs HSR&D CHIC, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana. The opinions contained in this paper are those of the authors and do not necessarily reflect those of the US Department of Veterans Affairs or the United States Government. The authors declare that they have no conflict of interests. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Virginia S. Daggett, PhD, RN, VACASE/R&D, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 W 10th St, Indianapolis, IN 46202 ([email protected]). Accepted for publication: September 27, 2014 Published ahead of print: November 28, 2014 DOI: 10.1097/NCQ.0000000000000096
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Health Care Systems Redesign Project to Improve Dysphagia Screening unselected adult primary care population and 75% among long-term care residents.1 Dysphagia often results in serious, poor health outcomes including aspiration pneumonia, malnutrition, sepsis, and death.2–4 Fortunately, timely treatment and management of dysphagia significantly improves patient outcomes, including reduced morbidity and hospital length of stay.5–7 A key first step in reducing the burden of dysphagia is to screen for swallowing problems and then refer patients for appropriate management. Given the limited availability of speech-language pathologists (SLPs) to assess and manage dysphagia, nurses are essential in the screening for dysphagia and in the multidisciplinary management of dysphagia. In 2006, Office of the Inspector General, Veterans Health Administration, issued a directive stating all veterans who were admitted to a Department of Veterans Affairs Medical Center (VAMC) must receive a screening for swallowing problems within 24 hours of hospital admission as part of the nursing admission assessment.3 In response, nursing staff at 1 tertiary VAMC, located in the Midwest, developed and implemented a dysphagia-screening tool for all veterans admitted to the facility. Subsequently, a Systems Redesign project was conducted to evaluate and improve the dysphagia-screening processes at this facility. This article describes the Systems Redesign dysphagia-screening project.
THE INTERVENTION: HEALTH CARE SYSTEMS REDESIGN METHODOLOGY Health care systems redesign methodology is an approach to process improvement that has been widely used to improve quality, enhance customer satisfaction, and improve performance.8–10 A fundamental principle of systems redesign is to base changes on small units of analysis among the process users. A salient feature of this methodology is that an experienced system redesign facilitator guides multidisciplinary teams that
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include frontline clinicians, managers, and researchers. This facilitator assists the team in identifying process improvement targets, discovering barriers or waste through process mapping, measuring performance parameters, and implementing rapid change to improve processes via rapid Plan, Do, Study, and Act (PDSA) cycles.9–16 This project was a 100-day quality improvement project to change provider practices. It was specifically designed to train frontline clinicians in systems redesign methodology to improve dysphagia-screening processes for all veterans admitted to the VAMC. KEY STAKEHOLDERS The VAMC administration identified key stakeholders who were responsible for dysphagia-screening and management; this group served as the Management Guidance Team, which was led by the nurse executive, the project’s sponsor. The Management Guidance Team included service chiefs across the following services: education, patient care services (nursing), neurology/medicine, nutrition, speech-language pathology, quality management/clinical applications coordination, and pharmacy. The systems redesign engineers were industrial engineers. METHODS Project charter Led by a systems redesign engineer, the Management Guidance Team developed a project charter to define the scope of the project and identify project targets (see Supplemental Digital Content, Table 1, available at: http://links.lww.com/JNCQ/A140). The Management Guidance Team identified frontline staff to form a multidisciplinary process action team. The Process Action Team included a dietician, speech-language pathologist, pharmacist, and nurses from acute care units, clinical applications, education, emergency department (ED), rehabilitation, and quality management.
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Understanding the current state Initially, the Process Action Team members shared their own experiences about dysphagia screening including positive and negative impressions. To understand other clinicians’ opinions and experiences with the current dysphagia-screening processes, the Process Action Team conducted interviews with their peers; they purposely sought to identify and interview peers who either were dissatisfied with the current dysphagiascreening practices or were resistant to changing the current practices. Concurrently, the team conducted direct observations of admissions in the ED and in the acute care units. The Process Action Team also conducted process mapping and spaghetti diagramming to define the current state. Most importantly, the team predetermined explicit metrics to evaluate the dysphagiascreening processes and the redesigned dysphagia-screening tool. These metrics included the time from admission to use of dysphagia-screening tool, the percentage of patients placed on nothing by mouth (NPO) status after a positive dysphagia screen, and the specificity and sensitivity of the dysphagiascreening tools. Process mapping Process mapping is one tool of systems redesign used to visualize a given process; in this case, the screening and management of dysphagia for all patients who were admitted to the facility. Process mapping has been used in diverse clinical settings14,16 and facilitates both the understanding of process flow and the identification of barriers to optimal flow that would serve as targets for improvement efforts.14 In this project, the team mapped each step of the current state, from time of assessment to placing a patient on NPO and ordering a SLP consult. Spaghetti diagram A “spaghetti diagram” was developed to create a visual representation of a process of the nursing admission process. The term “spaghetti” has been adopted because the di-
agrams often resemble spaghetti noodles. A spaghetti diagram begins with an illustration of the environment (ie, physical layout of the nurses’ station and medical rooms). Observers were instructed to draw lines on this illustration to reflect the movements, including repetitive movements that the nursing staff took to complete the patient admission (eg, a line might represent the walk a nurse made from a patient’s room to the supply closet). Admission data The Process Action Team reviewed facility admission data in the Computerized Patient Record System to determine the number of patients who had received a dysphagia screening upon admission and the results of those screenings. They also conducted direct observations of the admission process as patients were admitted from the ED to acute care units. PDSA cycles After the initial evaluation processes were completed, the Process Action Team began the PDSA cycle phase of the project.9 The main PDSA cycle focused on the redesign of the dysphagia-screening tool. The original dysphagia-screening tool consisted of 11 questions related to dysphagia risk factors and a box that nurses manually checked to initiate a speech-language consult if deemed necessary (see Supplemental Digital Content, Figure 1, available at: http://links.lww.com/ JNCQ/A152). Usability testing Usability tests were performed with the original and the redesigned dysphagiascreening tools in the Human Computer Interaction and Simulation Laboratory (HCL) at the Center of Excellence on the Implementing of Evidence-Based Practice. The purposes of the usability tests were 2-fold: (1) to test the performance of each tool and (2) to obtain nurses’ level of satisfaction with each tool. Process Action Team members participated as mock patients while 8 ambulatory care nurses evaluated the 2 different screening tools as
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Health Care Systems Redesign Project to Improve Dysphagia Screening applied to the mock patients. Prior to the usability tests, the SLP created mock patient cases that represented patients either with or without dysphagia. Each test was timed to measure the tool’s efficiency, and observers noted any unusual events and participants’ comments during each session. At the completion of the usability sessions, the nurse’s satisfaction was measured using a usability questionnaire. This questionnaire was a single 19-item tool that specifically measured satisfaction with ease of use, efficiency of the tool, content and organization of the content presented, comfort with the tool, error messaging to correct mistakes, and overall satisfaction. Analyses The data analyses included descriptive frequencies for baseline dysphagia-screening processes. Frequency counts and means were calculated for the positive and negative test results that were collected during the usability tests. Specificity and sensitivity as well as kappa statistics were calculated for each screening tool. RESULTS From the spaghetti diagrams that were produced as part of this project, the team learned that the admission/discharge nurses were challenged daily with accessibility to computers they shared with their unit peers. Immediate process improvements included the acquisition of laptops on roll-around computer carts for use by nurses for admissions and discharges. Because the nurses documented their admission assessments into the Computerized Patient Record System and the original dysphagia-screening tool was a template within the nursing admission template, the laptops on roll-around carts could be used to reduce delays in documentation of dysphagia screens and speech-language consults upon the time of admission. Patient and family educational posters were developed in response to process barriers.
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The team recognized the need to educate the patient and family members about the meaning of NPO, and the importance of keeping their family member from eating or drinking until the speech-language evaluation was conducted. These posters were strategically displayed at the entrance of dysphagic patients’ hospital rooms. Nursing educational posters were also developed to define the registered nurses’ roles in dysphagia evaluation and management. The dysphagia educational posters can be found at the Health Services Research & Development/VA Stroke Quality Enhancement Research Initiative Web site—http://www.queri.research. va.gov/tools/stroke-quality/dysphagia.cfm. The results of the chart abstractions demonstrated that 98% (2030/2071) of all veterans who were admitted to the VAMC, during the first year of dysphagia screenings, received the dysphagia screening. Among the veterans who were screened, 8% (166/2030) veterans had a positive dysphagia screen. On the basis of direct observations, half of the 16 observed veterans arrived on an acute care unit without physician orders, including no dietary orders. Although delays in dietary orders affected the initiation of medication administration and patient satisfaction, dietary orders were further delayed until the nursing admission assessment was conducted. The completion time of the nursing admission assessment, which included the dysphagia screen, ranged from 1 to 12 hours and averaged 3.5 hours from the patient admission to the dysphagia screen. Eighty-eight percent (n = 14) of observed veterans received an NPO order following a positive dysphagia screen because they failed the dysphagia screen. However, 4 of these 14 observed patients were found not to have dysphagia when they received an assessment by a member of the SLP service. The SLP dysphagia evaluations varied among the veterans’ presentations at the time of consult and followed the current standard of practice among SLPs. In some cases, veterans were evaluated by a Clinical Bedside Dysphagia Evaluation and in other cases,
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veterans were evaluated by Modified Barium Swallow (MBS).17 For example, if a veteran presented with a history of silent aspiration or significant evidence to support dysphagia, the SLP proceeded with an immediate MBS study. If it was unknown whether an MBS was required or whether a veteran was able to adequately participate in a MBS, the SLP began his or her initial evaluation with a Clinical Bedside Dysphagia Evaluation. After reflecting on the lessons learned from the current state mapping, peer interviews, and direct observations, the team considered both the content and format of the existing dysphagia-screening tool. There was a consensus that although the tool was used to document dysphagia screening in the overwhelming majority of admissions, the tool was ineffective for accurate dysphagia assessments and was not being utilized as designed (eg, some nurses had been repeatedly ridiculed by patients when they asked about problems with drooling, and hence those nurses sometimes skipped that particular question). Revised tool and outcomes The team concluded that a revised dysphagia assessment instrument should include both subjective (via questions to patients or family members) and objective data (through direct observations) (see Supplemental Digital Content, Figure 2, available at: http://links. lww.com/JNCQ/A153). The 7 questions for the new screening tool were selected on the basis of evidence in the literature regarding risk factors for dysphagia, clinical signs and symptoms of dysphagia, and clinical expertise from SLP staff. The revised screening tool changed 2 risk factors noted in the initial screening tool to questions directed to the patient or family. In addition, the revised tool also changed 5 additional risk factors from the initial screen into nursing observations. The redesigned tool was designed with an electronic trigger to order an SLP consult if the response to 1 or more of the 7 questions was “yes.” Some of the revisions on the screening were implemented to decrease nursing
confusion regarding the questions and to improve nursing compliance in completing the screening upon hospital admissions. Specific wording for the revised tool (see Supplemental Digital Content, Figure 2, available at: http: //links.lww.com/JNCQ/A153) was consistent with both the American Speech Hearing Association recommendations18–19 and The Joint Commission guidelines.20 Team members took the redesigned dysphagia-screening tool to their work areas, the ED and 2 acute care units, to obtain feedback from 8 employees regarding the original and redesigned dysphagia-screening tools. Each of the 8 clinicians preferred the redesigned dysphagia assessment tool over the original tool. Usability testing Using a Likert scale from 1 (strongly disagree) to 7 (strongly agree), the results of the usability tests demonstrated consistently higher scores (in the 5 to 7 range) in user satisfaction on each item with the revised dysphagia-screening tool when compared with the original dysphagia-screening tool. The results of the usability tests with the initial dysphagia-screening tool were similar to the results of the usability tests with the revised screening tool with the 8 patients. However, the initial dysphagia-screening tool was not designed to automatically trigger SLP consult ordering among the 8 patients, whereas the revised tool was designed to automatically trigger the ordering of SLP consults. Supplemental Digital Content, Table 2 (available at: http://links.lww.com/JNCQ/A141), provides the specificity and sensitivity of the dysphagia-screening tools. The kappa statistic was 0.85, indicating strong agreement between the old and new screening tools. The sensitivity and specificity for the old and new screenings were similar. The Process Action Team elected to implement the new screen in February 2008 and monitor its accuracy in performance with veterans. To date, the redesigned dysphagia screen remains a component of the nursing admission assessment at the local VAMC and is utilized for dysphagia
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Health Care Systems Redesign Project to Improve Dysphagia Screening screenings for all veterans admitted to the facility. DISCUSSION Dysphagia screening and dysphagia management continue to challenge clinicians in VA and in the private sector, and acute stroke teams are starting to apply Systems Redesign methodology to improve these processes for patients with stroke.11–12 Similar to this study, clinicians applied this methodology to improve inconsistent screening practices, develop a dysphagia-screening protocol, and implement practice changes for a registered nurse (RN) Bedside Swallow Assessment Tool.11–12 Clinicians also reported improvement in dysphagia screening before oral intake by 19% (P < 0.001) through the use of PDSA cycles.12 Although relatively few dysphagiascreening/management studies have used Systems Redesign methodology, this approach has been employed in Veterans Health Administration health care performance projects for a variety of measures and in diverse settings, including acute care.14–15 Findings from this study are similar to those of Parker et al14 because the culture in the VAMC encouraged cooperation and communication across multiple disciplines and included information technology support. More importantly, it is essential not to compromise satisfaction of frontline staff in projects to improve clinicians’ performance and quality of care.15 Thus, participation of frontline clinicians was critical in the change processes and success of this project. As in the current dysphagia Systems Redesign project, satisfaction questionnaires were given to frontline staff in other Systems Redesign projects, such as adherence to antibiotic prophylaxis prior to noncardiac surgery, to assess attitudes and perceptions of frontline staff regarding processes prior to implementation.15 This current dysphagia project demonstrated how critical the frontline nurses’ satisfaction was to
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the redesign of the dysphagia-screening tool and its performance, which, in turn, promoted their adherence to the new screening tool for adoption and sustainability in the VAMC. LIMITATIONS Limitations of this study included the use of mock patients for the usability tests. Thus, the items selected for the redesigned screening tool were not tested with veterans to determine whether the items were appropriate and valid. Although the patient scenarios reflected real dysphagic patient cases, the results of the usability tests may reflect bias because the Process Action Team members served as the mock patients and/or as facilitators who conducted the usability tests and collected the satisfaction data after the usability tests. Additional limitations included a single-site, a VA setting, the small sample size of 8 ambulatory care nurses for the usability tests, and the controlled environment of the HCL. CONCLUSION Systems Redesign methodology was an effective approach to address the multiple issues related to dysphagia screening at this 1 VAMC. This approach provided an opportunity for a multidisciplinary team to learn Systems Redesign processes and apply them in a performance improvement project that affects their daily practice and veterans’ quality of life. From this experience, members of this frontline staff can use these skills and apply them to implement other performance improvement projects within their own work units. In conclusion, process mapping assisted the dysphagia Process Action Team in identifying barriers early in the project. In turn, the team members successfully eliminated waste and barriers in clinical practices throughout the project. The Systems Redesign processes used in this study yielded an improved screening tool.
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REFERENCES 1. Robbins J, Kays S, McCallum S. Team management of dysphagia in the institutional setting. J Nutr Elder. 2007;26(3/4):59-104. 2. Altman KW, Yu G, Schaefer SD. Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Arch Otolaryngol Head Neck Surg. 2010;136(8):784-789. 3. Veterans Health Administration, Department of Veterans Affairs. VHA directive 2006-032: management of patients with swallowing (dysphagia) or feeding disorders. http://www1.va.gov/vhapublications/ ViewPublication.asp?pub ID=1422. Updated May 17, 2006. Accessed August 21, 2014. 4. Wilkins T, Gillies RA, Thomas AM, Wagner PJ. The prevalence of dysphagia in primary care patients: a HamesNet Research Network study. J Am Board Fam Med. 2007;20(2):144-150. 5. Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756-2763. 6. Daniels SK, Ballo LA, Mahoney M, Foundas AL. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Arch Phys Med Rehabil. 2000;81(8):1030-1033. 7. Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36(9):1972-1976. 8. Fairbanks CB. Using six sigma and lean methodologies to improve OR throughput. AORN J. 2007;86(1): 73-82. 9. Kopach-Konrad R, Lawley M, Criswell M, et al. Applying systems engineering principles in improving health care delivery. J Gen Intern Med. 2007;22(suppl 3):431-437. 10. The American Heart Association. Hospital uses “lean” manufacturing techniques to speed stroke care. http://newsroom.heart.org/news/hospital-uses-leanmanufacturing-239702. Published October 18, 2012. Accessed November 5, 2012. 11. Hines S, Wallace K, Crowe L, Finlayson K, Chang A, Pattie M. Identification and nurse management of dysphagia in individuals with acute neurological impairment. Int J Evid Based Healthc. 2011;9(2): 148-50.
12. Stoeckle-Roberts S, Reeves MJ, Jacobs BS, et al. Closing gaps between evidence-based stroke care guidelines and practices with a collaborative quality improvement project. Jt Comm J Qual Patient Saf. 2006;32(9):517-527. 13. Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. Cambridge, MA: Institute for Healthcare Improvement; 2007. IHI Innovation Series white paper. 14. Parker BM, Henderson JM, Vitgliano S, et al. Six Sigma methodology can be used to improve adherence for antibiotic prophylaxis in patients undergoing noncardiac surgery. Anesth Analg. 2007;104(1): 140-146. 15. Eldridge NE, Woods SS, Bonello RS, et al. Using Six Sigma processes to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units. J Gen Intern Med. 2006;21(suppl 2):S35-S42. 16. Aldarrab A. Application of Lean Six Sigma for patients presenting with ST-elevation myocardial infarction: the Hamilton Health Sciences experience. Healthc Q. 2006;9(1):56-61. 17. American Speech-Language-Hearing Association. Speech-language pathology medical review guidelines. http://www.asha.org/practice/reimbursement/ SLP-medical-review-guidelines. Copyright 2011. Accessed August 21, 2014. 18. American Speech-Language-Hearing Association. Roles of speech-language pathologists in swallowing and feeding disorders (position statement). ASHA Supplement. 2002e;22:73. 19. American Speech-Language-Hearing Association Ad Hoc Committee on the Scope of Practice in Speech-Language Pathology. Scope of practice in speech-language pathology (scope of practice document). http://www.asha.org/policy/SP2007-00283/#. Approved September 4, 2007. Accessed August 21, 2014. 20. The Joint Commission. Disease-Specific Care Certification Program: Stroke Performance Measurement Implementation Guide (Version 2.a), 2nd ed. http://www.jointcommission.org/assets/ 1/18/stroke pm implementation guide ver 2a.pdf. Updated October 2008. Accessed August 21, 2014.
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J Nurs Care Qual Vol. 30, No. 3, pp. 226–232 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Health Care Systems Redesign Project to Improve Dysphagia Screening Virginia S. Daggett, PhD, RN; Heather Woodward-Hagg, PhD; Teresa M. Damush, PhD; Laurie Plue, MA; Scott Russell, BS; George Allen; Linda S. Williams, MD; Neale R. Chumbler, PhD; Dawn M. Bravata, MD The purpose of this project was to improve dysphagia-screening processes in a tertiary Veterans Affairs Medical Center. The dysphagia-screening tool was redesigned on the basis of frontline clinician feedback, clinical guidelines, user satisfaction, and multidisciplinary expertise. The revised tool triggered a speech-language consult for positive screens and demonstrated higher scores in user satisfaction and task efficiency. Systems redesign processes were effective for redesigning the tool and implementing practice changes with clinicians involved in dysphagia screening. Key words: dysphagia, quality improvement, screening, systems redesign, veterans
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YSPHAGIA (or difficulty swallowing) is common in the United States, with the prevalence rate varying depending on the Author Affiliations: Department of Veterans Affairs VISN 11 Center for Applied Systems Engineering (VA-CASE) (Drs Daggett and Woodward-Hagg), Department of Veterans Affairs Research & Development (R&D) Service (Dr Daggett), Department of Veterans Affairs Systems Redesign Service (Dr Woodward-Hagg), and Department of Veterans Affairs Health Services Research & Development (HSR&D) (Center for Health Information and Communication) (Drs Damush, Williams, and Bravata and Ms Plue and Mr Russell), Richard L. Roudebush VA Medical Center, Indianapolis, Indiana; Department of General Internal Medicine and Geriatrics (Dr Damush), Department of Neurology (Drs Williams and Bravata), and Department of Internal Medicine (Dr Bravata), Indiana University School of Medicine; VA HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana (Drs Damush, Williams, and Bravata); Indiana University Center for Aging Research, Indianapolis, Indiana (Dr Damush); Regenstrief Institute, Indianapolis, Indiana (Drs Damush, Williams, and Bravata); Department of Veterans Affairs, Office of Informatics and Analytics, Analytics and Business Intelligence, Washington, DC (Mr Allen); and Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia (Dr Chumbler).
concomitant medical disorders. A populationbased study reported the overall prevalence of dysphagia to be 14% with 23% in an This study was internally supported by Department of Veterans Affairs Stroke QUERI 03-158, Indianapolis, Indiana. This work was performed at the Department of Veterans Affairs HSR&D CHIC, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana. The opinions contained in this paper are those of the authors and do not necessarily reflect those of the US Department of Veterans Affairs or the United States Government. The authors declare that they have no conflict of interests. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com). Correspondence: Virginia S. Daggett, PhD, RN, VACASE/R&D, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 W 10th St, Indianapolis, IN 46202 ([email protected]). Accepted for publication: September 27, 2014 Published ahead of print: November 28, 2014 DOI: 10.1097/NCQ.0000000000000096
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Health Care Systems Redesign Project to Improve Dysphagia Screening unselected adult primary care population and 75% among long-term care residents.1 Dysphagia often results in serious, poor health outcomes including aspiration pneumonia, malnutrition, sepsis, and death.2–4 Fortunately, timely treatment and management of dysphagia significantly improves patient outcomes, including reduced morbidity and hospital length of stay.5–7 A key first step in reducing the burden of dysphagia is to screen for swallowing problems and then refer patients for appropriate management. Given the limited availability of speech-language pathologists (SLPs) to assess and manage dysphagia, nurses are essential in the screening for dysphagia and in the multidisciplinary management of dysphagia. In 2006, Office of the Inspector General, Veterans Health Administration, issued a directive stating all veterans who were admitted to a Department of Veterans Affairs Medical Center (VAMC) must receive a screening for swallowing problems within 24 hours of hospital admission as part of the nursing admission assessment.3 In response, nursing staff at 1 tertiary VAMC, located in the Midwest, developed and implemented a dysphagia-screening tool for all veterans admitted to the facility. Subsequently, a Systems Redesign project was conducted to evaluate and improve the dysphagia-screening processes at this facility. This article describes the Systems Redesign dysphagia-screening project.
THE INTERVENTION: HEALTH CARE SYSTEMS REDESIGN METHODOLOGY Health care systems redesign methodology is an approach to process improvement that has been widely used to improve quality, enhance customer satisfaction, and improve performance.8–10 A fundamental principle of systems redesign is to base changes on small units of analysis among the process users. A salient feature of this methodology is that an experienced system redesign facilitator guides multidisciplinary teams that
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include frontline clinicians, managers, and researchers. This facilitator assists the team in identifying process improvement targets, discovering barriers or waste through process mapping, measuring performance parameters, and implementing rapid change to improve processes via rapid Plan, Do, Study, and Act (PDSA) cycles.9–16 This project was a 100-day quality improvement project to change provider practices. It was specifically designed to train frontline clinicians in systems redesign methodology to improve dysphagia-screening processes for all veterans admitted to the VAMC. KEY STAKEHOLDERS The VAMC administration identified key stakeholders who were responsible for dysphagia-screening and management; this group served as the Management Guidance Team, which was led by the nurse executive, the project’s sponsor. The Management Guidance Team included service chiefs across the following services: education, patient care services (nursing), neurology/medicine, nutrition, speech-language pathology, quality management/clinical applications coordination, and pharmacy. The systems redesign engineers were industrial engineers. METHODS Project charter Led by a systems redesign engineer, the Management Guidance Team developed a project charter to define the scope of the project and identify project targets (see Supplemental Digital Content, Table 1, available at: http://links.lww.com/JNCQ/A140). The Management Guidance Team identified frontline staff to form a multidisciplinary process action team. The Process Action Team included a dietician, speech-language pathologist, pharmacist, and nurses from acute care units, clinical applications, education, emergency department (ED), rehabilitation, and quality management.
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Understanding the current state Initially, the Process Action Team members shared their own experiences about dysphagia screening including positive and negative impressions. To understand other clinicians’ opinions and experiences with the current dysphagia-screening processes, the Process Action Team conducted interviews with their peers; they purposely sought to identify and interview peers who either were dissatisfied with the current dysphagiascreening practices or were resistant to changing the current practices. Concurrently, the team conducted direct observations of admissions in the ED and in the acute care units. The Process Action Team also conducted process mapping and spaghetti diagramming to define the current state. Most importantly, the team predetermined explicit metrics to evaluate the dysphagiascreening processes and the redesigned dysphagia-screening tool. These metrics included the time from admission to use of dysphagia-screening tool, the percentage of patients placed on nothing by mouth (NPO) status after a positive dysphagia screen, and the specificity and sensitivity of the dysphagiascreening tools. Process mapping Process mapping is one tool of systems redesign used to visualize a given process; in this case, the screening and management of dysphagia for all patients who were admitted to the facility. Process mapping has been used in diverse clinical settings14,16 and facilitates both the understanding of process flow and the identification of barriers to optimal flow that would serve as targets for improvement efforts.14 In this project, the team mapped each step of the current state, from time of assessment to placing a patient on NPO and ordering a SLP consult. Spaghetti diagram A “spaghetti diagram” was developed to create a visual representation of a process of the nursing admission process. The term “spaghetti” has been adopted because the di-
agrams often resemble spaghetti noodles. A spaghetti diagram begins with an illustration of the environment (ie, physical layout of the nurses’ station and medical rooms). Observers were instructed to draw lines on this illustration to reflect the movements, including repetitive movements that the nursing staff took to complete the patient admission (eg, a line might represent the walk a nurse made from a patient’s room to the supply closet). Admission data The Process Action Team reviewed facility admission data in the Computerized Patient Record System to determine the number of patients who had received a dysphagia screening upon admission and the results of those screenings. They also conducted direct observations of the admission process as patients were admitted from the ED to acute care units. PDSA cycles After the initial evaluation processes were completed, the Process Action Team began the PDSA cycle phase of the project.9 The main PDSA cycle focused on the redesign of the dysphagia-screening tool. The original dysphagia-screening tool consisted of 11 questions related to dysphagia risk factors and a box that nurses manually checked to initiate a speech-language consult if deemed necessary (see Supplemental Digital Content, Figure 1, available at: http://links.lww.com/ JNCQ/A152). Usability testing Usability tests were performed with the original and the redesigned dysphagiascreening tools in the Human Computer Interaction and Simulation Laboratory (HCL) at the Center of Excellence on the Implementing of Evidence-Based Practice. The purposes of the usability tests were 2-fold: (1) to test the performance of each tool and (2) to obtain nurses’ level of satisfaction with each tool. Process Action Team members participated as mock patients while 8 ambulatory care nurses evaluated the 2 different screening tools as
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Health Care Systems Redesign Project to Improve Dysphagia Screening applied to the mock patients. Prior to the usability tests, the SLP created mock patient cases that represented patients either with or without dysphagia. Each test was timed to measure the tool’s efficiency, and observers noted any unusual events and participants’ comments during each session. At the completion of the usability sessions, the nurse’s satisfaction was measured using a usability questionnaire. This questionnaire was a single 19-item tool that specifically measured satisfaction with ease of use, efficiency of the tool, content and organization of the content presented, comfort with the tool, error messaging to correct mistakes, and overall satisfaction. Analyses The data analyses included descriptive frequencies for baseline dysphagia-screening processes. Frequency counts and means were calculated for the positive and negative test results that were collected during the usability tests. Specificity and sensitivity as well as kappa statistics were calculated for each screening tool. RESULTS From the spaghetti diagrams that were produced as part of this project, the team learned that the admission/discharge nurses were challenged daily with accessibility to computers they shared with their unit peers. Immediate process improvements included the acquisition of laptops on roll-around computer carts for use by nurses for admissions and discharges. Because the nurses documented their admission assessments into the Computerized Patient Record System and the original dysphagia-screening tool was a template within the nursing admission template, the laptops on roll-around carts could be used to reduce delays in documentation of dysphagia screens and speech-language consults upon the time of admission. Patient and family educational posters were developed in response to process barriers.
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The team recognized the need to educate the patient and family members about the meaning of NPO, and the importance of keeping their family member from eating or drinking until the speech-language evaluation was conducted. These posters were strategically displayed at the entrance of dysphagic patients’ hospital rooms. Nursing educational posters were also developed to define the registered nurses’ roles in dysphagia evaluation and management. The dysphagia educational posters can be found at the Health Services Research & Development/VA Stroke Quality Enhancement Research Initiative Web site—http://www.queri.research. va.gov/tools/stroke-quality/dysphagia.cfm. The results of the chart abstractions demonstrated that 98% (2030/2071) of all veterans who were admitted to the VAMC, during the first year of dysphagia screenings, received the dysphagia screening. Among the veterans who were screened, 8% (166/2030) veterans had a positive dysphagia screen. On the basis of direct observations, half of the 16 observed veterans arrived on an acute care unit without physician orders, including no dietary orders. Although delays in dietary orders affected the initiation of medication administration and patient satisfaction, dietary orders were further delayed until the nursing admission assessment was conducted. The completion time of the nursing admission assessment, which included the dysphagia screen, ranged from 1 to 12 hours and averaged 3.5 hours from the patient admission to the dysphagia screen. Eighty-eight percent (n = 14) of observed veterans received an NPO order following a positive dysphagia screen because they failed the dysphagia screen. However, 4 of these 14 observed patients were found not to have dysphagia when they received an assessment by a member of the SLP service. The SLP dysphagia evaluations varied among the veterans’ presentations at the time of consult and followed the current standard of practice among SLPs. In some cases, veterans were evaluated by a Clinical Bedside Dysphagia Evaluation and in other cases,
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veterans were evaluated by Modified Barium Swallow (MBS).17 For example, if a veteran presented with a history of silent aspiration or significant evidence to support dysphagia, the SLP proceeded with an immediate MBS study. If it was unknown whether an MBS was required or whether a veteran was able to adequately participate in a MBS, the SLP began his or her initial evaluation with a Clinical Bedside Dysphagia Evaluation. After reflecting on the lessons learned from the current state mapping, peer interviews, and direct observations, the team considered both the content and format of the existing dysphagia-screening tool. There was a consensus that although the tool was used to document dysphagia screening in the overwhelming majority of admissions, the tool was ineffective for accurate dysphagia assessments and was not being utilized as designed (eg, some nurses had been repeatedly ridiculed by patients when they asked about problems with drooling, and hence those nurses sometimes skipped that particular question). Revised tool and outcomes The team concluded that a revised dysphagia assessment instrument should include both subjective (via questions to patients or family members) and objective data (through direct observations) (see Supplemental Digital Content, Figure 2, available at: http://links. lww.com/JNCQ/A153). The 7 questions for the new screening tool were selected on the basis of evidence in the literature regarding risk factors for dysphagia, clinical signs and symptoms of dysphagia, and clinical expertise from SLP staff. The revised screening tool changed 2 risk factors noted in the initial screening tool to questions directed to the patient or family. In addition, the revised tool also changed 5 additional risk factors from the initial screen into nursing observations. The redesigned tool was designed with an electronic trigger to order an SLP consult if the response to 1 or more of the 7 questions was “yes.” Some of the revisions on the screening were implemented to decrease nursing
confusion regarding the questions and to improve nursing compliance in completing the screening upon hospital admissions. Specific wording for the revised tool (see Supplemental Digital Content, Figure 2, available at: http: //links.lww.com/JNCQ/A153) was consistent with both the American Speech Hearing Association recommendations18–19 and The Joint Commission guidelines.20 Team members took the redesigned dysphagia-screening tool to their work areas, the ED and 2 acute care units, to obtain feedback from 8 employees regarding the original and redesigned dysphagia-screening tools. Each of the 8 clinicians preferred the redesigned dysphagia assessment tool over the original tool. Usability testing Using a Likert scale from 1 (strongly disagree) to 7 (strongly agree), the results of the usability tests demonstrated consistently higher scores (in the 5 to 7 range) in user satisfaction on each item with the revised dysphagia-screening tool when compared with the original dysphagia-screening tool. The results of the usability tests with the initial dysphagia-screening tool were similar to the results of the usability tests with the revised screening tool with the 8 patients. However, the initial dysphagia-screening tool was not designed to automatically trigger SLP consult ordering among the 8 patients, whereas the revised tool was designed to automatically trigger the ordering of SLP consults. Supplemental Digital Content, Table 2 (available at: http://links.lww.com/JNCQ/A141), provides the specificity and sensitivity of the dysphagia-screening tools. The kappa statistic was 0.85, indicating strong agreement between the old and new screening tools. The sensitivity and specificity for the old and new screenings were similar. The Process Action Team elected to implement the new screen in February 2008 and monitor its accuracy in performance with veterans. To date, the redesigned dysphagia screen remains a component of the nursing admission assessment at the local VAMC and is utilized for dysphagia
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Health Care Systems Redesign Project to Improve Dysphagia Screening screenings for all veterans admitted to the facility. DISCUSSION Dysphagia screening and dysphagia management continue to challenge clinicians in VA and in the private sector, and acute stroke teams are starting to apply Systems Redesign methodology to improve these processes for patients with stroke.11–12 Similar to this study, clinicians applied this methodology to improve inconsistent screening practices, develop a dysphagia-screening protocol, and implement practice changes for a registered nurse (RN) Bedside Swallow Assessment Tool.11–12 Clinicians also reported improvement in dysphagia screening before oral intake by 19% (P < 0.001) through the use of PDSA cycles.12 Although relatively few dysphagiascreening/management studies have used Systems Redesign methodology, this approach has been employed in Veterans Health Administration health care performance projects for a variety of measures and in diverse settings, including acute care.14–15 Findings from this study are similar to those of Parker et al14 because the culture in the VAMC encouraged cooperation and communication across multiple disciplines and included information technology support. More importantly, it is essential not to compromise satisfaction of frontline staff in projects to improve clinicians’ performance and quality of care.15 Thus, participation of frontline clinicians was critical in the change processes and success of this project. As in the current dysphagia Systems Redesign project, satisfaction questionnaires were given to frontline staff in other Systems Redesign projects, such as adherence to antibiotic prophylaxis prior to noncardiac surgery, to assess attitudes and perceptions of frontline staff regarding processes prior to implementation.15 This current dysphagia project demonstrated how critical the frontline nurses’ satisfaction was to
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the redesign of the dysphagia-screening tool and its performance, which, in turn, promoted their adherence to the new screening tool for adoption and sustainability in the VAMC. LIMITATIONS Limitations of this study included the use of mock patients for the usability tests. Thus, the items selected for the redesigned screening tool were not tested with veterans to determine whether the items were appropriate and valid. Although the patient scenarios reflected real dysphagic patient cases, the results of the usability tests may reflect bias because the Process Action Team members served as the mock patients and/or as facilitators who conducted the usability tests and collected the satisfaction data after the usability tests. Additional limitations included a single-site, a VA setting, the small sample size of 8 ambulatory care nurses for the usability tests, and the controlled environment of the HCL. CONCLUSION Systems Redesign methodology was an effective approach to address the multiple issues related to dysphagia screening at this 1 VAMC. This approach provided an opportunity for a multidisciplinary team to learn Systems Redesign processes and apply them in a performance improvement project that affects their daily practice and veterans’ quality of life. From this experience, members of this frontline staff can use these skills and apply them to implement other performance improvement projects within their own work units. In conclusion, process mapping assisted the dysphagia Process Action Team in identifying barriers early in the project. In turn, the team members successfully eliminated waste and barriers in clinical practices throughout the project. The Systems Redesign processes used in this study yielded an improved screening tool.
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