# Presentation: 102555

## SYSTEM REDESIGN OF THE DYSPHAGIA SCREENING TOOL AT RICHARD L. ROUDEBUSH VA MEDICAL CENTER

**Stroke QUERI**
- Dawn Bravata, MD
- Virginia S. Daggett, MSN, RN
- Teresa Damush, PhD
- Laura Plue, MS
- Scott Russell, BS
- George Allen, MS
- Neale Chumbler, PhD
- Heather Woodward-Hagg, MS
- Linda Williams, MD

**Frontline Clinical    **
**            ****Staff**
- Celine Alba-Patina, RN
- Tamra Arnold, Pharm-D
- David Bickel, RN, CAC
- Anna Bober, RN
- Randi Bruns, RN
- Rebecca Chapman, SLP
- Vonda Coley-Mathews, RN
- Jan Korte, RN
- Diane Longerbone, Dietician
- Katherine Sisk, RN

## OBJECTIVE

-    Describe use of Lean methodology to redesign dysphagia screen by a frontline, multidisciplinary  staff  in response to OIG directive.

## SIX SIGMA LEAN METHODOLOGY: DEMING PHILOSOPHY

| Six Sigma – 99.99966% performance level 
Creating Intellectual Capital |
| --- |
| Five Sigma- 99.977% performance level 
Competitive Breakthrough |
| Four Sigma- 99.370% performance
Continuous Improvement  |
| Three Sigma-93.32% performance level
Compliance |
| Two Sigma- 69.2% performance level
Capability |
| One Sigma- 31% performance 
Control |
| < One Sigma < 31% performance level
Containment  |

- Six Sigma = 3.4 per million units
- Five Sigma = 230 per
- million units
- Four Sigma = 6,210 per million units
- Three Sigma = 66,800
- per million units
- Two Sigma = 308,000
- per million units
- One Sigma = 690,000 per million units

- Most VA Performance
- Measures

**Notes:**
After WW II, went to Japan & taught Toyota the methodology statistical quality control and the significance of quality control in management. 

“Systems thinking” in healthcare to improve patient outcomes, reduce waste, and decrease overall costs 

## National Agencies or Organizational     Standards & Guidelines

- OIG Dysphagia Directive:
-      “...Nursing assessment...must be conducted on all incoming patient within 24 hours of admission at all VA facilities...”
- JCAHO Requirements:
-     “A screen for dysphagia should be performed on all ischemic/hemorrhagic stroke patients before being given food, fluids, or medication by mouth.”
- American Speech-Language-Hearing Association (ASHA) literature

## Current State at Roudebush VAMC

- Dysphagia treatment/management processes are not
- effective, resulting in:
- Dysphagia screening tool is inadequate (sensitive but not specific).
- Too many people place on NPO upon admission.
- Additional burden on nursing and speech/language pathology staff.
- Inadequate outpatient follow-up for dysphagia.
- Delay in administration of oral medications.
- Confusion with respect to diet requirements upon
-    discharge and positive screens.

## Voice of the Customer

- RNs:
- Screen is not user friendly
- RNs feel frustrated when consult is cancelled by physician; “Waste of time”
- Screen Questions do not pertain to the patient
- Physicians:
- Physicians not aware of the screen; rely on H&P
- Dieticians:
- Staff not aware of the assessment; patients not on NPO; trays are wasted

## PROCESS MAPPINGCURRENT STATE PRE-ASSESSMENT

- Patient Assigned to Ward

- Call Resident

- Orders Initiated

- Yes

- No

- ER Delays

- Room
- Cleaning

- Order
- Delays

- Med Pass
- Delays

- Wait for
- CT

- Family
- Providing
- Food

- 5S:
- No Admit RN
- Until 10:30a

- Patient
- Has Orders?

- Diet
- Order?

- Admit
- RN?

- Prior to
- 2:30pm?

- Admit RN Conducts Assessment

- RN Assigned Conducts Assessment

- PROCESS MAPPINGCURRENT STATE PRE-ASSESSMENT

## Current State Process Map

- Assessment
- Conducted

- RNs not
- Screening
- Correctly

- Order
- Consult?

- Lack of
- Education

- Other
- Patient
- Needs

- Clinical
- Status
- Change

- Unconscious
- Assessment

- Using
- Previous
- Assessment

- Admit
- RN
- Capacity

- RN
- Distractions

- No
- Sip Test

- Questions
- Not
- Appropriate

- MD Cancels
- Order

- H&P
- Impact
- Assessment

- RN Not
- Checking Consult
- Box

- No RN
- Policy

- Stroke
- History

- Clinical
- Judgment

- RN Choice
- Per Policy

- No Consult
- To Surgery

- Positive
- Screen?

- Dr.
- Approves
- Consult?

- NPO
- Order
- Signed?

- RN Makes NPO

- RN Contacts Dr for Order

- No Policy
- To Call

- Lack of
- Communication

- Patient
- Not Labeled
- NPO

- Assessment  Order Consult

## TIME TO ADMISSION ASSESSMENT

- Range = 1 hour to 12 hours

## ADMISSION AND DISCHARGE VOLUME BY HOUR OF DAY

##          SLP CONSULTS BY MONTH

- Dysphagia
- Screen
- Starts

- - 98% of Admissions Screened
- - 8.2% of Admissions
-   Screened Positive

## TIME FROM CONSULT TO SLP ASSESSMENT

- 28% (4/14) of observed patients
- were found to not have dysphagia
- by SLP

## Current State Summary

- ~50% of all observed patients (N=8) arrived on unit without orders
- Admission Assessment occurs an average of 3 hours following Assessment (range 1-12 hours)
- 2030/2071 (98.0%) of all veterans admitted to the facility received screening
- 166/2030 (8.2%) had a positive screening
- 46% of observed patients (N=14) were put on NPO following a positive screen
- 28% (N=14) of observed patients that failed screen were found to not have dysphagia

## PLAN, DO, STUDY, ACT (PDSA CYCLES)

| Stage | Description | Steps | Comments |
| --- | --- | --- | --- |
| 
Plan | Plan the test or observation, including a plan for collecting data. | 
State the objective of the test. 
Make predictions about what will happen and why. 
Develop a plan to baseline the current process and test the change. (Who? What? When? Where? What data need to be collected?) | Redesign the dysphagia screening tool. |
| 
Do | 
Try out the test on a small scale. | 
Carry out the test. 
Document problems and unexpected observations. 
Begin analysis of the data.   | Perform  usability testing on  the redesigned  tool. |
|  
Study | Analyze the data and 
study the results. | 
Complete the analysis of the data. 
Compare the data to your predictions. 
Summarize and reflect on what was learned.
Adapt, Adopt, Abandon? | Determine metrics of measurement  to analyze the  performance of the redesigned dysphagia screen and measure  sustainability. |
| 
Act | 
Refine the change, based on what was learned from the test. | 
Determine what modifications should be made. 
Prepare a plan for the next test. | Refine the screening tool based on data or analyze the performance of the original screen in general veteran population, not  limiting to acute stroke patients. |

## Slide 15

## Slide 16

## Usability Testing

- Patient Actors were used to provide consistent responses to each of the Users.
- Eight Users (RNs) interviewed each of the eight Patient Actors once, using the old design four times.
- Ordering of patients and test designs were balanced to offset learning factors.

## USABILITY TESTING LAYOUT

- Station 2

- Station 1

- Queue Area
- with Snacks

- Observer

- User

- Patient Actor

## Usability Study Feedback

- New design received consistently higher scores in user satisfaction
- New design showed fairly consistent improvement in task time (~40 sec mean)
- Old design performed similar screening, but did not perform similar consult ordering
- New design showed an increase in unnecessary consults

## USABILITY TESTING

**Notes:**
Usability Study Feedback
New design received consistently higher scores in user satisfaction
New design showed fairly consistent improvement in task time (~40 sec mean)
Old design performed similar screening, but did not perform similar consult ordering
New design showed an increase in unnecessary consults

## USABILITY STUDY SCREENINGS

- - 5 false positive screens
- due to patients with
- difficulty ‘swallowing
- large pills’

- 2 consults missed
- due to not checking
- the consult box

- - False Negatives
- screens due to one left
- side paralysis patient

## Slide 22

## SOLUTION RANKING

## DEVELOP CONTROL PLAN

- Process Monitors:
- Time from Admission to Dysphagia Screen
- % of Patients placed on NPO following positive screen
- Sensitivity of new screening tool
- - Positive Rate
- - False Positive Rate
- - False Negative Rate

## THOUGHTS FOR DISCUSSION

- For hospitalized veterans with acute stroke, the re-designed dysphagia screen did not improve performance.
- Change of patient status during hospitalization.
- Context of the screen:
-          -what discipline in terms of patient safety,
-           work flow
-          -when/where in point of care
- Consistency in policies: IG directive and JCAHO.
- Is nursing performing a dysphagia screen or an aspiration risk assessment?