Rapid Fire Team Presentation

1. Rapid Fire Team Presentation Name of Presenter: JoAnn Pelletier-Bressette

2. Who We Are Name of Organization: Waypoint Centre for Mental Health Care Location of Facility: Penetanguishene, Ontario Number of Patients/Residents/Clients: 312 bed psychiatric facility

3. AIM Learn and integrate strategies of sustainability into our organization’s falls improvement plans to ensure we increase the likelihood of sustaining practice change for prevention of falls and injury reduction while holding the gains over time

4. Team Members • Deborah Duncan – VP Regional Programs & Executive Sponsor • JoAnn Pelletier-Bressette – Nurse Manager Geriatrics & Team Lead • Debbie Branch – Occupational Therapist, Dual Diagnosis Program • Kim Dunn – Nurse Educator, Provincial Forensics • Maureen Thornton – Nurse Educator, Concurrent Disorders • Sherrie Fournier – Patient Safety/QI Coordinator • Lee Livingstone - Pharmacist

5. Current Falls Prevention Program in place: • Policy • Screening & Intervention Tree • Falls Screening Tool • Falling Leaves – visual tools

6. Hospital Wide Measures • Waypoint Centre has been collecting data since November 2010, with all programs reporting on the following four components: • Falls rate per 1000/patient days • Percentage of harmful falls (severity 1-4) • Percentage of patients with completed falls risk assessment on admission • Percentage of at risk patients with a falls prevention / protection intervention in place

7. FFLS Program & Measures • 8 patients from our Geriatrics Program identified as high risk fallers, used as the FFLS study group • Changes in data not reflective of hospital trends only episodes of falls in the study group • While the study group is not reflective of our total hospital population, the Geriatrics Program is our highest falls risk group • Results (to January 1012): Falls / 1000 patient days % of falls causing injury

8. FFLS Measures Percentage of "At Risk" Residents with a Documented Falls Prevention/Injury Reduction Plan Percentage of Residents with Completed Falls Risk Assessment on Admission No run chart available –at 100% with study group

9. Review Falls Change Ideas tested to date in your organization

10. Validity Study Measures • Process: • Four charts selected from three programs • Following data reviewed: • Heath care providers admission assessment • Any referral information from other sources • Medication prescribed on admission • “A” form • Any other information on the file within the first 72 hrs of admission • Scoring of blank tool completed without knowledge of the actual score recorded on admission • No record would be kept of actual name or CB number of pt. • 8 patients already audited on GSP were excluded from tool validation

11. Validity Study Outcomes

12. Validity Study Key Findings & Recommendations • Key findings • 92% of patients had a falls risk screening completed within 72 hrs of admission • 50% of the time, original assessor/auditors findings fell into the same range. Of these…. • 3 out of 11 patients(27%) would not have received interventions for falls risk as one of the 3 falls risk screening tools completed identified a score within the green range • Difficult to determine if all information was available to original assessor in order to do a complete assessment • Recommendations: • Regular communication to staff ensuring 100% compliance with policy • Evaluate opportunity for use of a quick screen tool • Collaborative approach to the completion of the falls screen • Clarification on terminology used on screening tool • Communication of findings from validity study related to the compliance and validation processes • Policy update, including completion of screening tool at first clinical

13. Chart Audit Measures • Process: • 8 charts audited: all Geriatric patients within the FFLS study group • Independent auditor used to audit charts

14. Chart Audit Key Findings & Recommendations • Key findings • Kardex main communication tool for visual falling leaf program • Falls Screening Tool consistently completed inaccurately, including wide range of different items to be scored. However….. • No one was screened lower than the chart review/tool screened as per data provided. This was great as every patient was a high risk, and did require and receive interventions to reduce risk of falls • Understanding of scoring the protective factors is not clear • Fear of falling due to high shine floor • Recommendations: • Provide definition /clarification on each item of the screening tool • Policy update • Review use of gloss finishes on floors

15. Lessons Learned on Sustaining Falls Improvement Work during Action Period • What advice would you give to other teams? • Team commitment to the initiative up front • Action on the low hanging fruit • Share successes across the organization • Learn from other teams’ success and challenges

16. Challenges to Sustaining Falls Improvement • What were some barriers? • Competing priorities within the organization leading to time and resource constraints • Great falls screening process in place – identifying areas of opportunity • What are some facilitators? • Strong falls intervention strategies already place • Strong commitment to falls reduction • How do you propose to move forward? • Refining of the screening tool and policy

17. 6 Month Post FFLS Sustainability Plans for Falls Improvement Work

18. 6 Month Post FFLS Sustainability Plan (continued)

19. Contact Information • Name: JoAnn Pelletier-Bressette • Email: jpelletier-bressette@waypointcentre.ca • Phone Number:705-549-3181 X2116 • Or • Name: Sherrie Fournier • Email: sfournier@waypointcentre.ca • Phone Number:705-549-3181 x2787