Implementation Example Fall/Fall Risk Clinical Process Guideline

1. Implementation ExampleFall/Fall Risk Clinical Process Guideline Joint Provider/Surveyor Training September 15, 2009 Karen M. Kinyon, M.S., R.N., C.P.H.Q., N.H.A. 1

2. FOCUS-PDCA • Find a process improvement opportunity • Organize a team who understands the process • Clarify the current knowledge of the process • Understand process variation andcapability • Start the Plan-Do-Check-Act cycle 2

3. Find a process improvement opportunity • High risk • Problem prone • Previous citations • Rank order all clinical process guidelines based on previous quality findings • Implementation plan for all guidelines 3

4. Organize an effort to work on improvementTeam/Group Make-up • Geriatric Resource Nurse • Director of Nursing/Assistant DON • Unit Managers • Maintenance/Safety Champion • Pharmacy • Medical Director • Staff Educator • Social Work • Admission Coordinator/MDS Coordinators • Restorative Staff 4

5. Clarify the current knowledge of the process • Clinical Process Guideline interpretation • Debra Ayres presentation • Clinical Process Guideline Team members • Review CPG • Care Step Process/Expectations/Rationale • Documentation Checklist: Audit tool • Tables 1, 2, & 3 5

6. Understand process variation andcapability • Current practice compared to best practice • Data collection • Data analysis/display • Identifying opportunities for improvement 6

7. Opportunities for Improvement • Fall assessment • History of previous falls • Medication-recent change, interactions • Appliances or devices-side rails • Environmental factors-floor mats, transfer bars • Physician participation in identification for medical cause of falls or medication related • Physician identifies reasons for falls after interventions 7

8. Select a strategy for continued improvement • Plan the improvement process • Do the improvement • Check the results and lessons learned • Act by adopting, abandoning or accepting the change 8

9. Plan the improvement process • Culture of safety • Resident & staff understanding of a safe environment • Positioning and bed safety • Documentation • Physician • Pharmacist • Nursing 9

10. Do the improvement • Policy & procedure review/revisions • Education of staff • Education of residents/families • Assessment & evaluation of current side rail use • Assessment & evaluation of equipment • Purchase of new equipment • Revision of forms • Development of new tools 10

11. Policy & Procedure Changes • Resident Safety Report • Investigation and Intervention Report • Physical Safety: Sleeping Environment • Physical Safety: Restraints • Physical Safety Assessment & Admission Procedure • Learning Tree 11

12. Forms/Brochure • Resident Safety Report • Investigation and Intervention Report • Physical Safety Assessment • Learning Tree • Resident/family brochure: Restraint Use in the Long-Term Care Setting 12

13. Education • Resident Council/Family • Resident/Family Brochure • Staff • RNs/LPNs/CNAs • Maintenance • Housekeeping • Activities • Therapy • Education/Resource Manual • Orientation Manual 13

14. Check the results/lessons learned • Follow-up data collection • Cost of change • Brochures • Positioning devices • Floor mats • Hand controls • Time • Change is difficult 14

15. Act by adopting, abandoning or accepting the change • On going training/education • Staff • Residents/families • Future state = no side rails • Reinforcement of change • Can’t go back • Celebrate success • On going monitoring and data collection 15

16. Resources • Process Guideline for Evaluation of Falls/Fall Risk http://www.michigan.gov/documents/mdch/bhs_CPG_Falls_Process_206279_7.pdf • AMDA Clinical Process Guidelines, 2003. • Centers for Medicare & Medicaid Services, State Operations Manual, Guidance to Surveyors for Long Term Care Facilities (2006) http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf. • TMF Health Quality Institute, the Medicare Quality Improvement Organization of Texas-LTC Ombudsman Initiative: Restraint reduction Toolkit, 2007 http://nursinghomes.tmf.org/Restraints/RestraintToolkit/tabid/548/Default.aspx. • MDCIS Guidelines for Use of Bed Rails in Long Term Care Facilities (March 1, 2001) http://www.michigan.gov/documents/cis_bhs_fhs_guidelines_bedrails_35726_7.pdf. 16

17. Questions? kkinyon@lakelandregional.org 1-269-473-3003 17