title: "Leaning" the process of venous thromboembolism prophylaxis.
abstract: BACKGROUND
  Lean principles have been used at Denver Health Medical Center since 2005 to streamline nonclinical processes. Despite allocation of significant resources, particularly the expense of low molecular weight heparin (LMWH), to prophylaxis of venous thromboembolism (VTE), the incidence of postoperative VTE was significantly worse than national benchmarks. VTE risk factors were not consistently assessed, and the prescribing of prophylaxis varied widely. Lean was employed to standardize and implement risk assessment and evidence-based VTE prophylaxis for the institution.
  
  
  METHODS
  In a rapid improvement event, a multidisciplinary group formulated an evidence-based risk assessment tool and clinical practice guideline for VTE prophylaxis, with plans for hospitalwide implementation and monitoring.
  
  
  RESULTS
  The effects were immediate and improved steadily with feedback to clinicians. Within six months, compliance with the standard approached 100%. One year after implementation, the use of LMWH decreased more than 60% below baseline, and the use of sequential compression devices decreased by nearly 30%. With increased use of unfractionated heparin, the cost savings on VTE prophylaxis exceeded $15,000 per month, for a total of $425,000 since implementation. Moreover, the incidence of VTE decreased markedly during the same period. By reducing VTE rates, a total cost savings of $6.2 million was estimated for the past 28 months.
  
  
  CONCLUSIONS
  Applying Lean to the clinical management of VTE prophylaxis improved compliance with standards and saved the hospital a significant amount of money. This was achieved without compromising clinical outcomes. This experience could be replicated at other institutions.
authors.affiliation: Denver Health Medical Center, Denver, USA. walter.biffl@dhha.org
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Matthew
authors.initials: M
authors.lastname: Beno
authors.forename: Philip
authors.initials: P
authors.lastname: Goodman
authors.forename: Amit
authors.initials: A
authors.lastname: Bahia
authors.forename: Allison
authors.initials: A
authors.lastname: Sabel
authors.forename: Karen
authors.initials: K
authors.lastname: Snow
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Steele
authors.forename: Claire
authors.initials: C
authors.lastname: Swartwood
authors.forename: Christiane
authors.initials: C
authors.lastname: Thienelt
authors.forename: Thomas D
authors.initials: TD
authors.lastname: MacKenzie
authors.forename: Philip S
authors.initials: PS
authors.lastname: Mehler
mesh_terms: D000925:Anticoagulants / Q000191:economics / Q000592:standards / Q000627:therapeutic use*; D014487:Centers for Medicare and Medicaid Services, U.S. / Q000191:economics / Q000592:standards; D003120:Colorado; D003362:Cost-Benefit Analysis; D006493:Heparin / Q000191:economics / Q000592:standards / Q000627:therapeutic use*; D006801:Humans; D048228:Intermittent Pneumatic Compression Devices; D019982:Organizational Case Studies; D009936:Organizational Innovation; D010043:Outcome and Process Assessment, Health Care; D010564:Personnel, Hospital / Q000193:education; D011183:Postoperative Complications / Q000191:economics / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D058996:Quality Improvement / Q000191:economics / Q000592:standards; D012052:Reimbursement, Incentive / Q000592:standards; D018570:Risk Assessment / Q000191:economics / Q000379:methods / Q000592:standards; D013192:Staff Development / Q000379:methods; D014481:United States; D054556:Venous Thromboembolism / Q000191:economics / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D006493:Heparin