System Redesign of the Dysphagia Screening Tool at Richard L. Roudebush VA Medical Center

1. 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

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

3. Six Sigma Lean Methodology: Deming Philosophy 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

4. 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

5. 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.

6. 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

7. PROCESS MAPPINGCURRENT STATE PRE-ASSESSMENT Family Providing Food Wait for CT Room Cleaning Med Pass Delays ER Delays Order Delays Admit RN Conducts Assessment Patient Has Orders? Diet Order? Admit RN? Patient Enters Hospital Patient Assigned to Ward Orders Initiated 5S: No Admit RN Until 10:30a Yes Prior to 2:30pm? No RN Assigned Conducts Assessment Call Resident

8. Current State Process Map Assessment  Order Consult Other Patient Needs No Consult To Surgery RNs not Screening Correctly Stroke History Lack of Education Lack of Communication H&P Impact Assessment RN Not Checking Consult Box No RN Policy Dr. Approves Consult? NPO Order Signed? Positive Screen? Order Consult? Dysphagia Assessment Conducted RN Makes NPO Clinical Judgment Clinical Status Change Patient Not Labeled NPO MD Cancels Order RN Choice Per Policy RN Contacts Dr for Order RN Distractions Questions Not Appropriate No Policy To Call Using Previous Assessment Admit RN Capacity Unconscious Assessment No Sip Test

9. Time to Admission Assessment Range = 1 hour to 12 hours

10. Admission and Discharge Volume by Hour of Day

11. SLP Consults by Month - 98% of Admissions Screened - 8.2% of Admissions Screened Positive Dysphagia Screen Starts

12. Time from Consult to SLP Assessment 28% (4/14) of observed patients were found to not have dysphagia by SLP

13. 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

14. Plan, DO, Study, ACT (PDSA Cycles)

17. 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.

18. Usability Testing Layout Queue Area with Snacks Station 2 Observer User Patient Actor Station 1

19. 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

20. Usability Testing

21. Usability Study Screenings • 2 consults missed • due to not checking • the consult box - 5 false positive screens due to patients with difficulty ‘swallowing large pills’ - False Negatives screens due to one left side paralysis patient

23. Solution Ranking

24. 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

25. 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?