Systematic Improvement Falls Prevention

1. Systematic ImprovementFalls Prevention Tom Kaster Improvement Advisor WHA • Courtesy Reminders: • Please place your phones on MUTE unless you are speaking (or use *6 on your keypad) • Please do not take calls and place the phone on HOLD during the presentation.

2. Today’s Call • Past 30 days • Staff Safety Assessment • Intervention Analysis • Model for Improvement (including PDSA and Small Tests of Change) • Next 30 days • Assessing your Change Ideas

3. Past 30 Days What went well? What could be improved?

4. New Resources in the Quality Center Falls Folder • Intervention Analysis Tools- Fall Prevention / Webinar / July Folder • Process Measurement Tools – Falls Prevention / References and Tool Kits Folder • New Driver Threads on the Falls Discussion Board • IHI-Falls Algorithm

5. Results of Survey Question: Primary Driver Interest

6. Upcoming Coaching Sessions • Patricia Quigley – July 23rd : Moving from assessment to improving results • Paul Frigoli – August 20th: Root cause analysis to improve outcomes

7. Poll Question #1: Fall Risk Assessment ≤24 Hours From Admission Which of the following best describes your facility in regards to completing a fall risk assessment within 24 hours of admission? • We complete an assessment on all patients and the care received matches the care plan identified at least 90% of the time • We complete an assessment on all patients but it is unknown if the care received matches the care plan • We do not complete a fall risk assessment consistently (less than 80% of the time) • We do not complete a fall risk assessment and would like to know more about best known practices

8. Science of Safety Recipe • Educate on the Science of Safety • Identify Defects (Staff safety assessment)* • Learn from Defects • Implement Teamwork & Communication Tools

9. What is a Defect?Anything you do not want to have happen again. A patient has a change in clinical status and is now a fall risk, but the care plan is not adjusted. A patient falls in the night trying to use the restroom. While being ambulated, a nurse assist a patient to the floor. The patient is fine but the nurse hurts her back.

10. Identifying Defects • TCAB Falls Tool Kit: Review the past 20 Falls in your facility • Ask staff how the next patient will be harmed • Engage those who are closest to the patients

11. The Staff Safety Assessment How will the next patient be harmed by a fall? -- One way to make harm visible– get staff thinking about safety and how to improve it • Identify clinical or operational problems that negatively impact patient safety (have or could) • Team review suggestions, set the agenda for discussion

12. Action Item #1 – Staff Safety Assessment Just two (2) very important questions for any clinical unit: Please describe how you think the next patient in your unit/clinical area may be harmed by a fall. Please describe what you think can be done to prevent or minimize this harm. Thank you for helping improve safety in our workplace! Available for you in Webinar Folder - July Packet

13. Poll Question #1 Results: Fall Risk Assessment ≤24 Hours From Admission Which of the following best describes your facility in regards to completing a fall risk assessment within 24 hours of admission? • We complete an assessment on all patients and the care received matches the care plan identified at least 90% of the time • We complete an assessment on all patients but it is unknown if the care received matches the care plan • We do not complete a fall risk assessment consistently (less than 80% of the time) • We do not complete a fall risk assessment and would like to know more about best known practices

14. Options for Collecting Assessments What Team Leaders can do: • Hand out a Staff Safety Assessment form to all staff, clinical and non-clinical, in the unit. • Assure participants of their confidentiality. • Establish a collection box or envelope OR alternatively use an on-line survey tool. • Set an end date for compiling all the responses.

15. Poll Question #2: What is your prediction for the Staff Safety Assessment? Which two of the primary drivers for fall prevention do you feel the majority of your staff’s suggestions will fall into (only select two)? • Fall Risk Assessment within 24 hours of admission • The need to reassess fall risk daily • Assessing and improving environmental factors • Establishing and consistently adhering to falls prevention interventions for all patients • Establishing and adhering to fall prevention and protection interventions for high risk patients

16. Every improvement is a change, but every change is not always an improvement

17. From Practice to Application:What to do next? Engaging front-line staff in innovation and quality improvement

18. Intervention Analysis • Analyze feasibility of the ideas from the Staff Safety Assessment • Analyze feasibility of secondary drivers • Do a final analysis of all the key ideas for each driver

19. Prioritizing Your Ideas • Review each response from the Staff Safety Survey • Categorize them based on primary driver

20. Fall Prevention Driver Diagram

21. Complete a Prioritization Matrix for Each Primary Driver

22. Driver Prioritization : Interventions for High Risk Patients Target Area Easy to Implement • Increase rounding frequency ≤ every 30 mins • Checklist for high risk room set up • Staff Safety Assessment idea #2 • Staff Safety Assessment idea • Enhance environment with fall protection devices Low Impact High Impact • Survey idea XX Available for you in Webinar Folder - July Packet Difficult to Implement

23. Action Item #3 – Assess and select an intervention Considerations: • How would this intervention work on the unit? • Who would be willing to try the intervention? • Could you try this within the next three days? For high risk patients, increase rounding frequency to ≤ 30 minutes emphasizing the 3 P’s: Positioning, Pain and Potty

24. Poll Question #2 Results: What is your prediction for the Staff Safety Assessment? Which two of the primary drivers for fall prevention do you feel the majority of your staff’s suggestions will fall into (only select two)? • Fall Risk Assessment within 24 hours of admission • The need to reassess fall risk daily • Assessing and improving environmental factors • Establishing and consistently adhering to falls prevention interventions for all patients • Establishing and adhering to fall prevention and protection interventions for high risk patients

25. AIM Statement –What are we trying to accomplish? • By when? • What? • For whom? • How much? Sample Aim Statements • By July 30th 2012 we want to insure that 100% of patient rooms in unit B have a completed environmental risk assessment • By July 21st, we want to insure 90% prevalence of the identified care plan for high risk patients in unit 5

26. Evaluate these AIM Statements • 5 North will improve teamwork and falls risk communication before January 2013 • The pilot unit will achieve zero falls with injury by September 2012 • By November 1, 100% of M/S patients will have documented fall risk assessment within four hours of admission. • By July 20th 2012 we want to establish hourly rounding for 60% of first shift nurses on unit C

27. Action Item #3 – Develop Your Initiative Specific Aim Statement

28. Model for Improvement Aims Measurement Change ideas Testing ideas before implementing changes

29. PDSA Cycle for Learning and Improving Act Plan Develop and test a bundle for high fall risk patients. Will test with one shift on one unit for one week What changes are to be made? Next cycle? Have shift and unit test new bundle for allotted time • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned Study Do

30. A P S D D S P A A P S D A P S D Repeated Use of the PDSA CycleSmall Tests of Change Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Change Ideas IHI – Adapted from “The Improvement Guide” by Lloyd Provost Very Small Scale Test

31. Change Ideas To be considered a real test… • Test was planned, including a plan for collecting data • Plan was carried out and data was collected • Time was set aside to analyze data and study the results • Action was based on what was learned

32. Action Item #4 – Test an Intervention Rule of 1 • Apply the Rule of 1: try the intervention with one patient, one nurse, one hour, one room. • Expand the participants systematically three nurses, six patients, one shift. • The goal is to have at least 20% of those doing the work to have a chance to try it. For high risk patients, increase rounding frequency to ≤ 30 minutes emphasizing the 3 P’s: Positioning, Pain and Potty

33. Action Item #5 – Make a Prediction and Measure Benefits: • Know what your doing is making an impact • Early indicator that you may be getting off track • Opportunity to identify obstacles • Answers the question: “Can we rapidly adopt this practice?” We predict that there will be 80% prevalence for half hourly rounding for high risk patients

34. Keep Track of Your Findings Available for you in Webinar Folder - July Packet

35. Fall Prevention Process Measures Process Measure Technique for measuring EMR Flag – All Admissions Morse fall risk card or EMR – Sample 10 per week Fall Risk Assessment and Interventions Audit (see TCAB document) – Sample 10 per week Hourly rounding check list Others---Please send me • Fall risk assessment within 24 hours of admission • Daily Risk Reassessment (Patient Plan Meets risk assessment) • Planned intervention was in place

36. Measurement Annotated Run Chart – plot small samples frequently over time. Environmental Risk Assessments on all Rooms Implemented High Risk Protocol (Bundle) Falls With Injury Rate Started Half Hour Rounding for High Risk June 2012-March 2013 “In God we trust.All others bring data.” W. E. Deming

37. The Next 30 Days • Tools available on WHA Quality Center: • Staff Safety Assessment Survey • AIM Statement Template • Assessment Matrix

38. Thank You! Questions? • Next webinar – August 7th • Patricia Quigley – July 23rd • Paul Frigoli – August 20th • Process Measures • Please take survey following webinar