Collaborative Fall Reduction Program

1. Collaborative Fall Reduction Program Jane Swaim, RN CNO, Senior Vice President, Nursing Jeannie Smith RN, Clinical Data Coordinator, Quality Management

2. How was the Project Selected? Senior Leadership and the Board decided to focus attention on fall rates in late 2009/early 2010. Despite many efforts over many years to address this issue, we had not been able to successfully lower fall rates to the Midas median goal of 2.85/1000 patient days. St Elizabeth Healthcare was a newly formed organization out of the St Elizabeth and St Luke Hospitals. Much work during 2009 was spent merging and re-aligning departments and the workforce. The 2010 Fall Reduction initiative was a project that spanned most departments, included all campuses, and required both nursing as well as allied health staff involvement. It helped to unify the campuses and staff as we worked on a joint quality project that bettered patient care.

3. What is the project’s situational analysis? The fall rate at our healthcare system was 3.4/1000 patient days in late 2009. The rates at individual campuses in the system fluctuated however all were above the national median. The Board and Administration felt lowering fall rates was so important, they also decided to include Falls as the Quality Gainsharing project for 2010, which further focused our efforts on this issue. Note: Gainsharing is a program at SEH where employees receive a bonus for achieving certain quality goals, pt. satisfaction goals and financial goals each year. The Senior VP Nursing led the Fall Reduction Project, and worked with Quality Management, Nursing Leaders and Nursing Staff, Pharmacy, Pt. Safety, Risk Management, the Medical Staff and Engineering to evaluate every aspect of fall prevention.

4. What was your project’s solution? • Utilized IHI framework to develop a system wide fall prevention program • Established a standardized method for collecting fall data • Implemented weekly Friday morning collaborative meetings where every fall throughout the system was reviewed by the Nurse Manager. • Initiated a multidisciplinary council, including allied health and ancillary departments • Developed tools for a marketing blitz to engage all staff, patients, physicians, families and visitors in fall prevention • Developed and disseminated a manager’s tool box and conducted training sessions with managers • Incorporated fall program in new hire orientation and annual MIDs • Introduced programs to facilitate fall prevention: "I Stop for Lights”, enhanced hourly rounding, shift and fall huddles • Initiated “Teach Back” method for educating patients/families • Established a multidisciplinary fall review workgroup that weekly reviews falls to identify causative factors and recommend changes in practice • Installation of call system with ability to interface with phones • Bed alarm system education provided with Plant Engineering’s assistance • Policy and procedure revision

5. St Elizabeth Falls/1000 Pt. Days What were your project’s results? The fall reduction program changed the culture across the system. Rates declined from 3.4/1000 pt. days in last quarter 2009 to 2.2/1000 pt. days in 1st quarter 2011, or a 35% reduction. The system fall rate is now well below the national median. St Elizabeth Healthcare Falls/1000 Pt. Days