Rapid Fire Template for Teams Facilitator: Dania Versailles, MScN

1. Rapid Fire Template for Teams Facilitator: Dania Versailles, MScN

2. About us 713 Montreal Road, Ottawa, ON. K1K 0T2 • Number of patients/residents/clients: • 300 beds2,700 births a year45,000 ER visits1,500 employees and 300 physicians

3. Objectives • Based on your team charter: • Reduce fall rate by 20% • Reduce injury rate by 20% • Increase compliance with administration of risk assessment on admission to 100% • Increase compliance with documentation of a customized intervention plan to 100%

4. Team members • Roles and responsibilities of each member in your team • Linda Lessard, Executive Partner, Director, Quality & Risk Management • Dania Versailles, Team Leader, Clinical Nurse Specialist • Madeleine Lauzon and Josée Berends, Clinical Educators • Renée Morissette, Unit Team Leader • Sylvie Denise Nault, Clinical Manager

5. Review of changes that have been tested at your institution

6. Review of changes that have been tested at your institution

7. Review of changes that have been tested at your institution

8. Review of changes that have been tested at your institution

9. Indicators • Include all measurement indicators related to your objective. These may include indicators measuring your basic data as well as all subsequent data, depending on last submission. They may also include staff or patient feedback. • Conduct audits and communicate results • Meditech report (number of falls and injuries/unit/month) • Feedback from members of the working group and staff (anecdotal) • Number of initiatives implemented

10. Lessons learned from work on sustainable and ongoing improvement in falls prevention during Action Periods • What advice would you give to other teams? • Importance of the PDSA cycles (document, assess and adjust planned activities) • Keep key champions and target teams up-to-date on activities • Use existing expectations (Accreditation Canada standards; the organization’s mission and strategic plan) as accountability elements • Create an environment that supports the intended objectives and complementary activities • What are your key ideas? • Visibility, presence and engagement of Falls Program representatives • Partnership and networking at multiple levels (internal via several sectors and external)

11. Challenges to sustaining improvement in falls prevention • What were the obstacles? • Outdated incident reports; workload distribution; working between meetings; irregular availability of support resources. • What were the facilitating factors? • Addition of resources (pharmacist); working group (monthly meetings); networking with internal and external partners; optimization of existing resources (LEAN Process) involvement of local level at national level; access to Meditech report system for audits/units; SHN and AIIAO support. • What next step would you suggest? • Supporting the addition of the program to the corporate QIP in order to reach other clinical and non-clinical sectors.

12. Next steps • Elementsyouwillwork on during Action Period #: • Potentially add the Falls Prevention Program to the hospital’s 2012-2013 Corporate Plan • Integrate falls into daily operational processes: • Patient care rounding- Clinical managers (med.) • Environmental assessment – Team supervisors (med.) • Communication: caucuses, inter-professional meetings, unit meetings

13. Next steps (cont.) • Inform physicians of changes as required • Create a post-fall analysis form (using a root cause analysis approach) • Establish a sub-group to develop a flyer for patients and families • Increase practices and resources that offer alternatives to restraints and revise the P&P with the RNAO’s BPG (to be released in January 2012) • Promote monthly “Non-Violent Crisis Intervention” training (CPI)

14. Contact • Name: Dania Versailles, Clinical Nurse Specialist • Email: dversailles@montfort.on.ca • Phone: 613-746-4621, ext. 3706