Venous Thromboembolism (VTE)

How can we safely, properly and confidently care for patients who are diagnosed with a blood clot?

WORK AT
Mayo Clinic - Center for Innovation

TIMELINE
August 2011- August 2012

ROLE
Lead Service Designer/ Design Researcher

ACTIVITIES
Patient / Provider observations
Stakeholder interviews
Workshop facilitation
Design challenge creation
Prototype development and testing
Process mapping
Synthesis presentation
Secondary research / literature review


OUTCOME
We created new patient education materials and videos that were distributed across all Mayo Clinic locations. We created a successful crowdsource idea challenge that resulted in two ideas being prototyped. We reached consensus on treatment across providers at different Mayo Clinic locations.


Insights

There was a lack of standardization across the Mayo Clinic Enterprise for prevention, diagnosis and treatment of venous thromboembolism (VTE) that was due to a:

  1. There was limited communication across the three Mayo Clinic locations about standard procedures

  2. Care Team staff didn’t realize the seriousness of VTEs as the number 1 leading hospital caused death

  3. There was a lack of clarity on the importance between different protocols

  4. No standard time to use sequential compression devices (SCDs) led to varying usage even though they are ordered standard for every hospitalized patient

 

Outcome

Several mini projects emerged from the research:

  1. Get Your Squeeze On Idea Challenge – to improve the use of SCDs in the hospital. We found literature stating 18 hours was recommended for DVT prevention and created that as the Mayo standard. We launched an idea campaign and took to the top two ideas to prototype and test.

  2. Standardization Summit – we brought together the most important providers, nurses and quality change agents to co-create a standardization process for preventing, diagnosing and treating VTEs as a best practice across the Mayo Clinic Enterprise.

  3. Standardized of patient education material

  4. Standardization and improvement of staff training

Patient empathy map of a patient who has developed blood clots

Patient empathy map of a patient who has developed blood clots

Sorting activity at summit

Sorting activity at summit

 

Process

The Chief Patient Safety Officer and Administrator of Quality Management came to our team to help create a lean system to appropriately identify and treat patients with acute VTE effectively and efficiently. 

I started with understanding the current landscape by conducting an extensive literature review, interviewing 32 clinical staff, 31 patients and observing in multiple clinical units across Mayo Clinic locations (MN, WI, FL, AZ). I then mapped patient flows and synthesized insights from my interviews and research.

Process mapping of emergency department in Mankato and how they treat patients who come in with a blood clot

Process mapping of emergency department in Mankato and how they treat patients who come in with a blood clot

I conducted my own usability test sleeping with sequential compression devices to gain a better perspective of what patients in the hospitals are feeling. I soon realized how restricting the tubing was, how it made me feel trapped and how very little sleep I got from having my legs squeezed every 30 seconds. I presented my insights through a documentary style video of waking up every 30 minutes due to the machine to create empathy of what a patient's night is like in the hospital. 

Mayo Brother's supporting wearing SCDs

Mayo Brother's supporting wearing SCDs

“My doctor said if I walked to the bathroom and hallway I could go without them (SCDs) at night.”

- Patient

Sequential compression device inaccessible under patient bed

Sequential compression device inaccessible under patient bed

Our team wrapped up the year with a summit the Chief Patient Officer and Administrator of Quality, and I co-facilitated various activities throughout the day. While patients were not able to be at the workshop we made their presence felt and referred to them frequently throughout the day through the use of posters hanging around the room.  

Individual provider mapping of key components of treating a patient with blood clots

Individual provider mapping of key components of treating a patient with blood clots