Using Skin and Falls Data for Process and Patient Outcomes Improvement 815

1. 1 Using Skin and Falls Data for Process and Patient Outcomes Improvement#815 Monday August 9, 2010 The current session is on �Using Skin and Falls Data for Process and Patient Outcomes Improvement.� We�re glad you chose this class to attend and believe you will be receiving information you can apply back at your facilities.The current session is on �Using Skin and Falls Data for Process and Patient Outcomes Improvement.� We�re glad you chose this class to attend and believe you will be receiving information you can apply back at your facilities.

2. 2 Faculty Virginia (Kim) Fitz, RN VANOD Coordinator Stratton VA Medical Center in Albany, New York and Jennifer Batt, RN, BSN, MBA VANOD Program Manager VA Western New York Healthcare (VAWNYHS) The faculty for today�s class is myself �Kim Fitz� (you can find me in outlook under Virginia Fitz). I am from the Stratton VA Medical Center in Albany New York. and Jennifer Batt of the VA Western New York Healthcare System We are the VANOD Coordinators within the VISN 2. The faculty for today�s class is myself �Kim Fitz� (you can find me in outlook under Virginia Fitz). I am from the Stratton VA Medical Center in Albany New York. and Jennifer Batt of the VA Western New York Healthcare System We are the VANOD Coordinators within the VISN 2.

3. We will discuss how the Stratton Albany Medical Center uses skin data for process and patient outcome improvements and discuss methods used at Western New York to introduce, implement and use the VANOD National Falls templates 3 We will discuss how the Stratton Albany Medical Center uses skin data (collected from the VANOD Skin templates) for Process and Patient Outcomes Improvement. Jennifer will discuss the methods used at Western New York to introduce, implement and use the VANOD National Falls templates We will discuss how the Stratton Albany Medical Center uses skin data (collected from the VANOD Skin templates) for Process and Patient Outcomes Improvement. Jennifer will discuss the methods used at Western New York to introduce, implement and use the VANOD National Falls templates

4. 4 HOUSE KEEPING Cell Phones Please turn off or change to vibrate If you must answer a call or text message please leave the room Before we begin we need to take care of a few Housekeeping details. Please turn off or change your cell phones to vibrate. Out of respect to the other participants in the class, we ask that you please leave the room if you must answer a call.Before we begin we need to take care of a few Housekeeping details. Please turn off or change your cell phones to vibrate. Out of respect to the other participants in the class, we ask that you please leave the room if you must answer a call.

5. 5 HOUSE KEEPING Please No questions during the presentation Questions written on a 3X5 card will be answered at the conclusion of the presentation, time permitting All questions and answers will be posted on the web Please hold your questions during the presentation. Questions should be written on the 3X5 cards provided. There will be time for Questions at the end of the class, and if any questions were not answered today, the answers will be provided for you after the conference on the VeHU website. Please hold your questions during the presentation. Questions should be written on the 3X5 cards provided. There will be time for Questions at the end of the class, and if any questions were not answered today, the answers will be provided for you after the conference on the VeHU website.

6. 6 Using VANOD Skin Data to improve patient outcomes : Validating Data, Trending, and Sharing By Virginia �Kim� Fitz VANOD Coordinator The Stratton VA Medical Center is part of the VA Healthcare Network in Upstate New York. We provide comprehensive services to Veterans including a comprehensive outpatient services. The hospital holds 156 in patients beds. There are two Medical Surgical Units, one Intensive Care Unit, one Acute In-Patient Behavioral Health Unit, and two Long Term Care Units. The Stratton VA Medical Center is part of the VA Healthcare Network in Upstate New York. We provide comprehensive services to Veterans including a comprehensive outpatient services. The hospital holds 156 in patients beds. There are two Medical Surgical Units, one Intensive Care Unit, one Acute In-Patient Behavioral Health Unit, and two Long Term Care Units.

7. OBJECTIVES ������� Describe how to access and organize skin data from the VANOD Skin reports ������� Explain a way to approach data validation ������� State strategies for collaboration and communication ������� Discuss problem identification and resolution 7 Describe how to access and organize skin data from VANOD Skin Reports: show how to navigate through VANOD Reports to get Skin Data Explain a way to approach data validation: how to trend and identify themes State Strategies for collaboration and communication: Share examples of who I collaborate with in our facility Discuss problem identification and resolution: Share examples of how we did this. Describe how to access and organize skin data from VANOD Skin Reports: show how to navigate through VANOD Reports to get Skin Data Explain a way to approach data validation: how to trend and identify themes State Strategies for collaboration and communication: Share examples of who I collaborate with in our facility Discuss problem identification and resolution: Share examples of how we did this.

8. Resources Available Patient Level Access 8 Here is where you can get Resources to get Patient Level Access.Here is where you can get Resources to get Patient Level Access.

9. VANOD HOME PAGE http://vaww.vanod.med.va.gov 9 Here is VANOD�s Home Page: Go to ProClarity ReportsHere is VANOD�s Home Page: Go to ProClarity Reports

10. Patient Level Detail Access 10 VANOD Production Page from VHA Support Service Center (VSSC) Click on the icon: Frequently Asked QuestionsVANOD Production Page from VHA Support Service Center (VSSC) Click on the icon: Frequently Asked Questions

11. 11 The first topic shown is on how to get � Patient Level Detail� access. Here is the form that needs to be completed. The first topic shown is on how to get � Patient Level Detail� access. Here is the form that needs to be completed.

12. VSSC PAGE: With VANOD Reports: Here is another way to find resources to get Patient Level Detail Access�Here is another way to find resources to get Patient Level Detail Access�

13. VSSC PAGE: With VANOD Reports: 13 Once you click on the skin reports, this window opens up and a drop down box has many choices. Once you click on the skin reports, this window opens up and a drop down box has many choices.

14. Resource for definitions and validation of skin data In order to get to the resources, click on � Data Definitions and Supporting Documentations.� In order to get to the resources, click on � Data Definitions and Supporting Documentations.�

15. How to Get to Patient Detail Access? If you click on �Data Validation Instructions�, it gives you information how to get access to Patient Detail (Social Security Number) Work load data. Having this access gives you the ability to look into CPRS ( to a particular patient) to validate the information that National Data Base collected is accurate. If you click on �Data Validation Instructions�, it gives you information how to get access to Patient Detail (Social Security Number) Work load data. Having this access gives you the ability to look into CPRS ( to a particular patient) to validate the information that National Data Base collected is accurate.

16. Locate Local Skin Data Here is how to get to local skin data. 16 Once you have the Patient Level Access: here is how you get your local skin data.Once you have the Patient Level Access: here is how you get your local skin data.

17. VSSC PAGE: With VANOD Reports 17 Click to �Skin Risk Reports� to locate data at the facility level Click to �Skin Risk Reports� to locate data at the facility level

18. Access to Patient Level 18 Click on Station ReportsClick on Station Reports

19. Get to Your Facility Level. 19 You click on your VISN first, and then the facility box is available to give you access to your particular facility You click on your VISN first, and then the facility box is available to give you access to your particular facility

20. Overview of the Report Viewer 20 This page opens up. On the left, you will see the Categories of data measures that are captured from the VANOD Skin Assessment Note Templates. So, every time a nurse enters information in the Skin Note Template, data is being collected called �Health Factors� behind the scenes. These health factors are then categorized into these listed. To get to patient detail, you click here. This page opens up. On the left, you will see the Categories of data measures that are captured from the VANOD Skin Assessment Note Templates. So, every time a nurse enters information in the Skin Note Template, data is being collected called �Health Factors� behind the scenes. These health factors are then categorized into these listed. To get to patient detail, you click here.

21. Overview of the page with choices 21 This page opens up. On the left, you will see the Categories of data measures that are captured from the VANOD Skin Assessment Note Templates. What does this mean? Each time an entry is made in the skin Notes, health factors (data) are being collected behind the scenes. Then they categorize the data into these listed. This is done by collecting health factors are collected and categorized into these categories. Click on �Patient Detail� Category to get to Patient level information This page opens up. On the left, you will see the Categories of data measures that are captured from the VANOD Skin Assessment Note Templates. What does this mean? Each time an entry is made in the skin Notes, health factors (data) are being collected behind the scenes. Then they categorize the data into these listed. This is done by collecting health factors are collected and categorized into these categories. Click on �Patient Detail� Category to get to Patient level information

22. Sample of Patient Detailed Data 22 Here is an example of a spread sheet of patient detail. The patient�s name and Social security number , day of admission and discharge, and treating specialties are provided for you. Treating specialty is defined as to what service the patient was admitted under, i.e. urology service, orthopedics service etc. To maintain confidentiality, we cut out this information on this slide. I highlighted categories that did not meet criteria : you would identify that with a �NO� under the appropriate category. For example, Pink high-light is identifying that all daily skin inspection (every 24 hours) documentation was not completed for this particular patient. Yellow highlighted area indicated that the Category: initial skin assessment within 24 hours of admission was not completed as required. Realize that the data has limitations. Patient�s data is collected only after the patient is discharged. So, if you have a patient who has been there for 6 months, data will not be captured until he/she is discharged. If within the patient�s stay (there was one day of not following the required charting), there would be a �no� under that particular category. So it is a �all� or �none� law. If the patient has been in for 6 months, and there was only one day that the patient missed a skin assessment, a �no� would still appear. Here is an example of a spread sheet of patient detail. The patient�s name and Social security number , day of admission and discharge, and treating specialties are provided for you. Treating specialty is defined as to what service the patient was admitted under, i.e. urology service, orthopedics service etc. To maintain confidentiality, we cut out this information on this slide. I highlighted categories that did not meet criteria : you would identify that with a �NO� under the appropriate category. For example, Pink high-light is identifying that all daily skin inspection (every 24 hours) documentation was not completed for this particular patient. Yellow highlighted area indicated that the Category: initial skin assessment within 24 hours of admission was not completed as required. Realize that the data has limitations. Patient�s data is collected only after the patient is discharged. So, if you have a patient who has been there for 6 months, data will not be captured until he/she is discharged. If within the patient�s stay (there was one day of not following the required charting), there would be a �no� under that particular category. So it is a �all� or �none� law. If the patient has been in for 6 months, and there was only one day that the patient missed a skin assessment, a �no� would still appear.

23. Filter and Organize Data  23 Now that you have this data, it can be pretty large and overwhelming. I am going to share with you how I filter and sort the information. Now that you have this data, it can be pretty large and overwhelming. I am going to share with you how I filter and sort the information.

24. Export to Excel Spread Sheet You are able to export the categories, and patient detail into the Excel Spreadsheet. Click on �Select format� and choose Excel in one of the drop down box choices. You are able to export the categories, and patient detail into the Excel Spreadsheet. Click on �Select format� and choose Excel in one of the drop down box choices.

25. Export to Get Spread Excel Sheet Then click on �Export�Then click on �Export�

26. Sorting Data 26 In order to filter out the patient list by all the no�s in each category given, Click on Data, > then click on �Filter� Button, 3. Then click on the arrow button Click on the particular category you want to focus on and click on the down arrow. In order to filter out the patient list by all the no�s in each category given, Click on Data, > then click on �Filter� Button, 3. Then click on the arrow button Click on the particular category you want to focus on and click on the down arrow.

27. Sorting Data 27 Example: you click on the drop down box for �initial skin assessment� on admission day, the option opens for yes or no. �Yes� means that the patient had a completed initial skin assessment. �No� would mean, not met the criteria within the defined time frame (within 24 hours). Example: you click on the drop down box for �initial skin assessment� on admission day, the option opens for yes or no. �Yes� means that the patient had a completed initial skin assessment. �No� would mean, not met the criteria within the defined time frame (within 24 hours).

28. 28 �..data will show only those patients who were not compliant with initiating skin assessment on admission within 24 hours. Categorizing all the �no�s� together makes it easier to validate the information in the CPRS. You would have to click on filter button again to get back to the original list. �..data will show only those patients who were not compliant with initiating skin assessment on admission within 24 hours. Categorizing all the �no�s� together makes it easier to validate the information in the CPRS. You would have to click on filter button again to get back to the original list.

29. Application of skin data: Useful data for your facility 29 How data can be useful for your facility: How data can be useful for your facility:

30. Application of this Data: 30 When you look at the results of the category data that needs improvement: look for factors that are frequently found. Can you see a trend? Is there a theme emerging with the data. -Is one unit particularly making errors more frequently than others? -Could it be occurring only on weekend or same shift? -Could it be same staff member? When you look at the results of the category data that needs improvement: look for factors that are frequently found. Can you see a trend? Is there a theme emerging with the data. -Is one unit particularly making errors more frequently than others? -Could it be occurring only on weekend or same shift? -Could it be same staff member?

31. Indentify Frequent Type of Errors 31 Next consideration is identifying a frequent type of error that could skew the data. Look at data that has the highest numberof errors: i.e. Admission Skin not completed in 24 hours� and see if you can see a trend as to the cause: i.e. use of the Skin Reassessment template instead of Admission Skin Assessment Template. Are there common errors i.e. such as: -wrong skin template used -mislabeling pressure ulcers, is staging the pressure ulcer accurate? -cutting and pasting skin templates -Are interventions initiated if patient is at risk for skin breakdown? i.e. Braden Score 18 or less? Next consideration is identifying a frequent type of error that could skew the data. Look at data that has the highest numberof errors: i.e. Admission Skin not completed in 24 hours� and see if you can see a trend as to the cause: i.e. use of the Skin Reassessment template instead of Admission Skin Assessment Template. Are there common errors i.e. such as: -wrong skin template used -mislabeling pressure ulcers, is staging the pressure ulcer accurate? -cutting and pasting skin templates -Are interventions initiated if patient is at risk for skin breakdown? i.e. Braden Score 18 or less?

32. What do you do with the information? 32 Once you get the data, and identify trends, What do you do with it? Once you get the data, and identify trends, What do you do with it?

33. What do you do with the data once identified? 33 This is where real work occurs. This is where critical thinking skills comes in. Find if data can be explainable: Are there things going on, that puts a barrier from giving care and documenting properly? Establish a team. Get as much help as you can. Think who in your facility would be most helpful. This is where real work occurs. This is where critical thinking skills comes in. Find if data can be explainable: Are there things going on, that puts a barrier from giving care and documenting properly? Establish a team. Get as much help as you can. Think who in your facility would be most helpful.

34. Example: Identifying Barriers of Documentation :Redundancy in Charting 34 Example: Redundancy in charting: We found that there were many places we were documenting skin assessment: i.e. Admission note, transfer note and daily note and on discharge note. Having skin documentation in multiple places, put less importance using the skin templates. Problem solve: Streamlining documentation so that it is not in multiple places, improved compliance. Currently, skin is documented in one place (VANOD Skin Note Templates) Example: Redundancy in charting: We found that there were many places we were documenting skin assessment: i.e. Admission note, transfer note and daily note and on discharge note. Having skin documentation in multiple places, put less importance using the skin templates. Problem solve: Streamlining documentation so that it is not in multiple places, improved compliance. Currently, skin is documented in one place (VANOD Skin Note Templates)

35. Example: Identifying Barriers of Documentation :Infrequent Users 35 Another Example: We also identified that staff, who made a lot of errors in documenting, were infrequent users of the skin templates: i.e. part time workers, nurses who floated to multiple units, agency nurses, and students. To problem solve that: we re-educate the staff on the proper way to document skin templates. We met with the agencies, nursing instructors and the manager of the float pool to ensure they were all re-educated. Then follow up with them when errors were made. This helped improved data in the following months. Another Example: We also identified that staff, who made a lot of errors in documenting, were infrequent users of the skin templates: i.e. part time workers, nurses who floated to multiple units, agency nurses, and students. To problem solve that: we re-educate the staff on the proper way to document skin templates. We met with the agencies, nursing instructors and the manager of the float pool to ensure they were all re-educated. Then follow up with them when errors were made. This helped improved data in the following months.

36. Problem Solving: Collaboration: It�s a Group Effort 36 Again, this is not a one man team. It takes a group. Examples of who I use in my facility to help problem solve.Again, this is not a one man team. It takes a group. Examples of who I use in my facility to help problem solve.

37. Nurse Manager�s Role: 37 Nurse Managers are interested in knowing the skin data for their unit. They particularly are interested if their staff are appropriately treating and documenting skin correctly. Is one staff member a repeat offender of improperly charting, despite counseling? Is it a Compliance or learning issue? This is where the Nurse Manager needs to address the problem if it is a compliance issue. Nurse Managers are interested in knowing the skin data for their unit. They particularly are interested if their staff are appropriately treating and documenting skin correctly. Is one staff member a repeat offender of improperly charting, despite counseling? Is it a Compliance or learning issue? This is where the Nurse Manager needs to address the problem if it is a compliance issue.

38. 38 I share the data trends with these groups and committees and ask for suggestions or insight that I may have not considered. In our facility, Nursing Documentation committee is very helpful to update changes in documentation templates, but also in identifying where charting can be more streamlined. We recently developed a RN Practice Council: which assist in ensuring that best practice is utilized for skin care management. We need to share with Nurse leaders (Nurse Managers, Nursing Supervisors, and Nurse Executives) solutions and problem solving ideas. Without their support and buy in, it�s really hard to put new processes in place. So think who in your facility could be a great resource for you to go to , to problem solve some of identified categories that need improvement.I share the data trends with these groups and committees and ask for suggestions or insight that I may have not considered. In our facility, Nursing Documentation committee is very helpful to update changes in documentation templates, but also in identifying where charting can be more streamlined. We recently developed a RN Practice Council: which assist in ensuring that best practice is utilized for skin care management. We need to share with Nurse leaders (Nurse Managers, Nursing Supervisors, and Nurse Executives) solutions and problem solving ideas. Without their support and buy in, it�s really hard to put new processes in place. So think who in your facility could be a great resource for you to go to , to problem solve some of identified categories that need improvement.

39. Collaboration: Group Effort (cont. ) 39 Who else did I reach out to? -I talked to nurses 1 to 1: they are the end users, and can tell you what the barriers are. -Nurse Educators are used to re-educate and to ensure competency on the Skin documentation and management of wounds, when we discover a need to educate a group of staff. -Pressure Ulcer Committee member is a great resource to use. They are content experts for their unit, and can be used as resource for the staff. I have an ongoing rapport with them, and have them validate the wounds when a new wound is identified in the reports. They take more ownership from their ward to ensure the patient is being taken care of appropriately. Who else did I reach out to? -I talked to nurses 1 to 1: they are the end users, and can tell you what the barriers are. -Nurse Educators are used to re-educate and to ensure competency on the Skin documentation and management of wounds, when we discover a need to educate a group of staff. -Pressure Ulcer Committee member is a great resource to use. They are content experts for their unit, and can be used as resource for the staff. I have an ongoing rapport with them, and have them validate the wounds when a new wound is identified in the reports. They take more ownership from their ward to ensure the patient is being taken care of appropriately.

40. Examples of data improvement 40 The following slides are examples of how we made improvements with identified skin trends we found. The following slides are examples of how we made improvements with identified skin trends we found.

41. Increase in Hospital Acquired Pressure Ulcers from VANOD report 41 Last year, we found that there was a significant rise in our hospital Acquired pressure data. It was 8%. This is above the National standard of 5%. We looked in the CPRS and reviewed the skin templates that indicated a hospital acquired pressure ulcers. We discover that one particular med surg. floor had the highest number of pressure ulcers. Here are the themes we found: -We identified the nurses were documenting incorrectly with current pressure ulcers. The current pressure ulcers were documented as if it were a new pressure ulcer. From VANOD Data base, it captured the wound as a new pressure ulcer. -We identified that there were wounds that were not pressure ulcers, but were stasis ulcers or diabetic ulcers, or contact dermatitis were charted as if it were pressure ulcer. -We identified that there were some pressure ulcers staged incorrectly. Last year, we found that there was a significant rise in our hospital Acquired pressure data. It was 8%. This is above the National standard of 5%. We looked in the CPRS and reviewed the skin templates that indicated a hospital acquired pressure ulcers. We discover that one particular med surg. floor had the highest number of pressure ulcers. Here are the themes we found: -We identified the nurses were documenting incorrectly with current pressure ulcers. The current pressure ulcers were documented as if it were a new pressure ulcer. From VANOD Data base, it captured the wound as a new pressure ulcer. -We identified that there were wounds that were not pressure ulcers, but were stasis ulcers or diabetic ulcers, or contact dermatitis were charted as if it were pressure ulcer. -We identified that there were some pressure ulcers staged incorrectly.

42. �Reminder Due Report� in VISTA Here is the web link where clinical reminders can be downloaded.� http://vista.med.va.gov/reminders/ 42 �Clinical Reminders Report� is a very useful tool that is available to us through VISTA. It has the ability to capture reports related to patients who has pressure ulcers. VANOD offers this link, which gives instructions how to create the �Reminders Due Reports for your facility. This report is linked to the VANOD Skin Template: Our local IT Department and (Ad Pac and CACs) downloaded instructions and set up this report at our local facility. �Clinical Reminders Report� is a very useful tool that is available to us through VISTA. It has the ability to capture reports related to patients who has pressure ulcers. VANOD offers this link, which gives instructions how to create the �Reminders Due Reports for your facility. This report is linked to the VANOD Skin Template: Our local IT Department and (Ad Pac and CACs) downloaded instructions and set up this report at our local facility.

43. �Reminder Due Report� in VISTA 43 In our local report, here are the 3 options you can run through VISTA. �AL� indentifies Albany. #1: option is to report of any new pressure ulcers found during patient�s stay. #2: option is to get a tally of all patients who currently have a pressure ulcer during their stay (this is identified by health factors captured in the VANOD Skin Note Template). Remember these patients are only those who are currently here. Anyone who is discharged, is not on the list. #3: option is to get identify patients who has a Braden Score of 18 or less, and with no care plans initiated. Wound Care nurse, VANOD Nurse and Nurse Managers has access to this report, (if they choose to). Most Reports are done weekly. In our local report, here are the 3 options you can run through VISTA. �AL� indentifies Albany. #1: option is to report of any new pressure ulcers found during patient�s stay. #2: option is to get a tally of all patients who currently have a pressure ulcer during their stay (this is identified by health factors captured in the VANOD Skin Note Template). Remember these patients are only those who are currently here. Anyone who is discharged, is not on the list. #3: option is to get identify patients who has a Braden Score of 18 or less, and with no care plans initiated. Wound Care nurse, VANOD Nurse and Nurse Managers has access to this report, (if they choose to). Most Reports are done weekly.

44. Verify if wound is a pressure ulcer and staged appropriately: 44 With this Report: we can now find solutions to the problems identified: Rounding with wound care nurse: -Making rounds weekly with the wound care nurse -helped identify if the wound was actually a pressure ulcer - to identify if the wound was staged appropriately - looked if there were appropriate interventions or consults placed for patients with a pressure ulcer? The wound care nurse documents on the current skin template by adding an addendum to the skin template. She gives her assessment on the wound, and validate the stages of the wound, along with her recommendations for treatment. She also talked to the patient�s nurse and gave recommendations/ taught / or shared her findings. Wound care nurse and pressure ulcer committee nurse member would addendum skin notes if documentation was inaccurate i.e. staging. Follow up: Key to success. Each nurse identified (who charted incorrectly) was re-educated on their chartingWith this Report: we can now find solutions to the problems identified: Rounding with wound care nurse: -Making rounds weekly with the wound care nurse -helped identify if the wound was actually a pressure ulcer - to identify if the wound was staged appropriately - looked if there were appropriate interventions or consults placed for patients with a pressure ulcer? The wound care nurse documents on the current skin template by adding an addendum to the skin template. She gives her assessment on the wound, and validate the stages of the wound, along with her recommendations for treatment. She also talked to the patient�s nurse and gave recommendations/ taught / or shared her findings. Wound care nurse and pressure ulcer committee nurse member would addendum skin notes if documentation was inaccurate i.e. staging. Follow up: Key to success. Each nurse identified (who charted incorrectly) was re-educated on their charting

45. Identified Cut and Paste, Using the Health Factors 45 One of the major areas we identified needing improvement was to avoid cutting and pasting skin documentation. Staff discovered how to cut and paste as a short cut, and affected our skin data. When cutting and pasting, health factors were not being captured. When looking in the CPRS, it appeared as though they were documenting appropriately, but data from VANOD consistently showed a �no� when there was actual note template there. One of the major areas we identified needing improvement was to avoid cutting and pasting skin documentation. Staff discovered how to cut and paste as a short cut, and affected our skin data. When cutting and pasting, health factors were not being captured. When looking in the CPRS, it appeared as though they were documenting appropriately, but data from VANOD consistently showed a �no� when there was actual note template there.

46. Sample of Charting with Health Factors Captured 46 Here is a sample of Skin assessment Note. You can see that on the bottom of the template is a boxed area with words. This is where health factors from the skin template is gathered. Every entry you put into the template is gathering data. Here is a sample of Skin assessment Note. You can see that on the bottom of the template is a boxed area with words. This is where health factors from the skin template is gathered. Every entry you put into the template is gathering data.

47. Sample of charting to indicate cutting and pasting in CPRS 47 Here is a Skin Note without the box. This is a good indication that cutting and pasting is going on. No health factors are showing. In order to be validate this, There is a report you can get out of CPRS to see validate if Health Factors were being captured. Here is a Skin Note without the box. This is a good indication that cutting and pasting is going on. No health factors are showing. In order to be validate this, There is a report you can get out of CPRS to see validate if Health Factors were being captured.

48. Validate Capturing Health Factor in CPRS 48 Click on �reports� in bottom tab of CPRS.Click on �reports� in bottom tab of CPRS.

49. In CPRS 49 Under Clinical Reports, choose Health Summary Button Under Clinical Reports, choose Health Summary Button

50. 50 It gives a menu for ADHOC Health Summary, another set of choices opens up. Scroll down until you see PCE Health Factors Selected It gives a menu for ADHOC Health Summary, another set of choices opens up. Scroll down until you see PCE Health Factors Selected

51. PCE Health Factors Selected 51 Click on �Pce Health Factors� Selected Click on �Pce Health Factors� Selected

52. Topic for Health Factor 52 File Selection window opens up: Type in the what health factors you want to view: i.e. �Skin�File Selection window opens up: Type in the what health factors you want to view: i.e. �Skin�

53. Select Health Factors 53 Choices related to skin information are available. Health factors I chose ones that are common that everyone fills out on the skin templates, i.e. skin temperature, skin turgor or color. Use the > button to bring the information over to other side of screen. Then click OK. Choices related to skin information are available. Health factors I chose ones that are common that everyone fills out on the skin templates, i.e. skin temperature, skin turgor or color. Use the > button to bring the information over to other side of screen. Then click OK.

54. 54 If you know your patient�s length of stay and date of stay, you can fill out the Occurrence limit and time limit. If I am aware of patient�s admission and discharge data, I can adjust the occurrences and time frame to match. Then click OKIf you know your patient�s length of stay and date of stay, you can fill out the Occurrence limit and time limit. If I am aware of patient�s admission and discharge data, I can adjust the occurrences and time frame to match. Then click OK

55. What Date Do You See Missing? 55 The report would look like this. As you can see, the date for the 18th is missing. What does this mean? That means selected skin health factors were not captured for that day. National VANOD data views this as: Skin Assessment Template has not been filled out for that day. But�..if there is a Skin Note Template completed for that day, (on the 18th) it would indicate that cutting and pasting has occurred. The report would look like this. As you can see, the date for the 18th is missing. What does this mean? That means selected skin health factors were not captured for that day. National VANOD data views this as: Skin Assessment Template has not been filled out for that day. But�..if there is a Skin Note Template completed for that day, (on the 18th) it would indicate that cutting and pasting has occurred.

56. Sharing Skin Data 56 Now that you have an understanding of how we use our data to improve our skin care and outcomes, We need to share our skin data with the hospital. We need to share when we are doing great, and when we need to improve. Now that you have an understanding of how we use our data to improve our skin care and outcomes, We need to share our skin data with the hospital. We need to share when we are doing great, and when we need to improve.

57. Sharing of Data Outcomes 57 One of our ways of communicating how well we are performing with Skin is using a Newsletter: the Nurse Education News. Here is a sample of March�s News letter. This lets everyone know our skin data outcomes. One of our ways of communicating how well we are performing with Skin is using a Newsletter: the Nurse Education News. Here is a sample of March�s News letter. This lets everyone know our skin data outcomes.

58. Information Shared in News Letter: 58 I reviewed high-lights, and give recognition when we do well �. For Example: Our hospital ideally would like all of our data to be above 90% in compliance with appropriate Skin Documentation. We are sharing the status of the categories that VANOD data base has for us. I reviewed high-lights, and give recognition when we do well �. For Example: Our hospital ideally would like all of our data to be above 90% in compliance with appropriate Skin Documentation. We are sharing the status of the categories that VANOD data base has for us.

59. 59 Information Shared in News Letter: Compare National Level With the VANOD Skin data, it gives us the ability to compare our facility with VISN or even National level. This can really set a benchmark for ourselves: In this example, I am sharing how our patient population who are �at risk� for skin break down is: compared to national average. Even our community acquired pressure ulcers rate is higher compared to National Average. With the VANOD Skin data, it gives us the ability to compare our facility with VISN or even National level. This can really set a benchmark for ourselves: In this example, I am sharing how our patient population who are �at risk� for skin break down is: compared to national average. Even our community acquired pressure ulcers rate is higher compared to National Average.

60. Information Shared in News Letter: Share areas that need improvement I not only need to share the positive but also areas where we need to improve. In reality the % will fluctuate. But if it continues to trend the wrong way, this is a trigger to look deeper to see what is the cause. I not only need to share the positive but also areas where we need to improve. In reality the % will fluctuate. But if it continues to trend the wrong way, this is a trigger to look deeper to see what is the cause.

61. Conclusion: Reflection of Care: 61 Ending Note: As a reminder: Data should not be driving our care. Remember Data should be reflecting our outcomes and quality of care. Ending Note: As a reminder: Data should not be driving our care. Remember Data should be reflecting our outcomes and quality of care.

62. Resources if any questions: 62 If you have any questions, the national VANOD group is especially helpful. Use the VANOD Contacts. If you have any questions, the national VANOD group is especially helpful. Use the VANOD Contacts.

63. Resources for questions 63 Here are the list of all the National VANOD Leaders if you have questions. I contact them frequently if I can�t find answers. They are very approachable and help lead you to the right place to find answers.Here are the list of all the National VANOD Leaders if you have questions. I contact them frequently if I can�t find answers. They are very approachable and help lead you to the right place to find answers.

64. VANOD Coordinator Contacts 64 Also you can contact VANOD Coordinators who have volunteered to be resource for you. Also you can contact VANOD Coordinators who have volunteered to be resource for you.

65. 65 Here is where you can find me if you have any further questions.Here is where you can find me if you have any further questions.

66. 66 This presentation will highlight how the VANOD National Fall Templates were implemented in Western New York.This presentation will highlight how the VANOD National Fall Templates were implemented in Western New York.

67. VAWNYHS 67 The VA Western New York Healthcare System is a unified and integrated system with two main inpatient locations, the acute care facility located in Buffalo NY shown on the left and the Community Living Center facility located in Batavia NY shown on the right. The VA Western New York Healthcare System is a unified and integrated system with two main inpatient locations, the acute care facility located in Buffalo NY shown on the left and the Community Living Center facility located in Batavia NY shown on the right.

68. 68 Learning Objectives To Learn successful strategies for Implementing the VANOD fall templates Avoiding pitfalls during implementation Acquiring tips for use during implementation Use of fall data collected to effectively promote optimal patient outcomes The objectives of the presentation are that participant will learn successful strategies for launching and implementing the VANOD fall templates, learn some pitfalls to avoid during the launch, acquire tips that may be used during implementation and finally see how the fall data collected can be used to effectively promote optimal patient outcomes. This section of the presentation will cover an overview of the learning objectives for the implementation of the National Fall Templates, explain the role of the National Patient Safety Goals and how they relate to the fall reduction program, review the definition of a fall and how to access the templates. The objectives of the presentation are that participant will learn successful strategies for launching and implementing the VANOD fall templates, learn some pitfalls to avoid during the launch, acquire tips that may be used during implementation and finally see how the fall data collected can be used to effectively promote optimal patient outcomes. This section of the presentation will cover an overview of the learning objectives for the implementation of the National Fall Templates, explain the role of the National Patient Safety Goals and how they relate to the fall reduction program, review the definition of a fall and how to access the templates.

69. National Patient Safety Goals Patient identification (matching to the service) Communication among caregivers Medication safety Health care-associated infections Medication reconciliation Patient falls Flu & pneumonia immunization Surgical fires Patient involvement Pressure ulcers Focused risk assessment (suicide; home fires) Recognition and response to changes in patient condition Encourage patients� active involvement in their own care as a patient safety strategy Universal Protocol for Preventing Wrong Site Surgery 69 For the roll out of the VANOD falls template focus was on two National Patient Safety Goals that are addressed by the VANOD Falls note templates. Goal # 6, Patient falls and; Goal # 13 to encourage patients� active involvement in their own care as a patient safety strategy. Utiliziing the VANOD falls templates were viewed as a way to help better meet these goals. Implementation was proposed to and approved by the Falls Committee and the Nurse Executive and the decision was made to proceed with launch in January 2009! For the roll out of the VANOD falls template focus was on two National Patient Safety Goals that are addressed by the VANOD Falls note templates. Goal # 6, Patient falls and; Goal # 13 to encourage patients� active involvement in their own care as a patient safety strategy. Utiliziing the VANOD falls templates were viewed as a way to help better meet these goals. Implementation was proposed to and approved by the Falls Committee and the Nurse Executive and the decision was made to proceed with launch in January 2009!

70. 70 VANOD fall templates are an integral part of our fall reduction program: They include evaluation of the patient population, settings, services provided They include interventions to reduce fall risk due to environmental factors Staff education Patient education An ongoing evaluation of the effectiveness of the fall reduction program The use of the VANOD falls templates can become an integral part of a fall reduction program: This includes evaluation of the patient population, the settings, the services provided Interventions to reduce fall risk due to environmental factors, it involves both staff and patient education An ongoing evaluation of the effectiveness of the fall reduction program The use of the VANOD falls templates can become an integral part of a fall reduction program: This includes evaluation of the patient population, the settings, the services provided Interventions to reduce fall risk due to environmental factors, it involves both staff and patient education An ongoing evaluation of the effectiveness of the fall reduction program

71. 71 It focuses on identification of ways in which the patient and his or her family can report concerns about safety in an environment that encourages them to do so. Goal 13 was new in 2009  Goal 13, new in 2009, focuses on the identification of ways in which the patient and his or her family can report concerns about safety in an environment that encourages them to do so. Inclue this as part of training to the staff. This may be a cultural change for them. Goal 13, new in 2009, focuses on the identification of ways in which the patient and his or her family can report concerns about safety in an environment that encourages them to do so. Inclue this as part of training to the staff. This may be a cultural change for them.

72. 72 A review of the definition of a fall assures that the trainers, the staff and administration all viewed falls the same way. According to VANOD a fall is defined as: �an unplanned descent to the floor/ground�. In the future the falls data will be automatically collected into a VANOD national database from which reports can be generated that will assist in preventing and reducing the number of falls and the severity of those falls thereby improving patient outcomes. Until the national collection of falls data is ready for use Western New York decided to create a local database into which data about each fall is entered. Set up and maintained by the Performance Mgt Dept and Patient Safety Officer it uses Vista for tracking every fall that occurs and is reported as an incident report. The VANOD national Fall templates are available from the clinical Reminders web site.A review of the definition of a fall assures that the trainers, the staff and administration all viewed falls the same way. According to VANOD a fall is defined as: �an unplanned descent to the floor/ground�. In the future the falls data will be automatically collected into a VANOD national database from which reports can be generated that will assist in preventing and reducing the number of falls and the severity of those falls thereby improving patient outcomes. Until the national collection of falls data is ready for use Western New York decided to create a local database into which data about each fall is entered. Set up and maintained by the Performance Mgt Dept and Patient Safety Officer it uses Vista for tracking every fall that occurs and is reported as an incident report. The VANOD national Fall templates are available from the clinical Reminders web site.

73. 73 This screen print shows the home page for the Clinical Reminders. Scrolling down on this webpage will take the user to the VANOD Fall Reminder template. This screen print shows the home page for the Clinical Reminders. Scrolling down on this webpage will take the user to the VANOD Fall Reminder template.

74. 74 Using these links the install guide and each of the two templates may be downloaded. Your IT department can assist with this. Using these links the install guide and each of the two templates may be downloaded. Your IT department can assist with this.

75. What we did to plan the Launch A good plan is key to success 75 A good plan is necessary as a key to success! The slogan, Plan Your Work and then Work Your Plan is a good goal for any new implementation, This section looks at the various aspects of planning an effective template launch. A good plan is necessary as a key to success! The slogan, Plan Your Work and then Work Your Plan is a good goal for any new implementation, This section looks at the various aspects of planning an effective template launch.

76. Plan your work and work your plan! We Recruited a group interested in helping: The VANOD Site Coordinator Nurse Managers Clinical Nurse Leads Nurse Educators The Fall Prevention / Safe Patient Handling Coordinator 76 Recruit a group interested in helping to plan, train and implement the use of the Falls templates. This group may include such individuals as the VANOD Site Coordinator, Nurse Managers, Clinical Nurse Leads, Nurse Educators and the Fall Prevention / Safe Patient Handling Coordinator Getting their support and buy in be a key at any facility. Recruit a group interested in helping to plan, train and implement the use of the Falls templates. This group may include such individuals as the VANOD Site Coordinator, Nurse Managers, Clinical Nurse Leads, Nurse Educators and the Fall Prevention / Safe Patient Handling Coordinator Getting their support and buy in be a key at any facility.

77. VANOD Coordinator�s RoleDuring Planning To Develop the training tools Share the new templates and tools with planning committee Recruit staff nurses to help with training and support Train the trainers 77 The VANOD Coordinator will likely take the following role during planning. Chair meetings, develop the training tools, share the new templates and tools with planning committee educating those who would help with the training. This is a �train the trainers� approach. The committee members can assist in recruiting other staff nurses - RNs one from each unit, to help with training and support during the launch process. To be sure the training can be presented within the 60 minute training time frame the committee members can rehearse the presentations as a group. The VANOD Coordinator will likely take the following role during planning. Chair meetings, develop the training tools, share the new templates and tools with planning committee educating those who would help with the training. This is a �train the trainers� approach. The committee members can assist in recruiting other staff nurses - RNs one from each unit, to help with training and support during the launch process. To be sure the training can be presented within the 60 minute training time frame the committee members can rehearse the presentations as a group.

78. Planning for Training We had weekly meetings over a period of four weeks to plan the training by Establishing Objectives of the training Building an Agenda for the training Fine tuning the program to fit one hour timeframe And developing a Training Schedule A key to the success of the training was the decision that all staff would be taken off their unit for the training 78 Weekly committee meetings just prior to the launch allows the training to stay fresh. This group should establish the objectives for the training, determine the agenda and develop a training schedule with the goal of all RNs are trained within 30days of the template implementation. A decision should be made to insure the training is without distraction by seeing that all staff are trained off the unit. This key decision must be supported by the Nurse Executive. Weekly committee meetings just prior to the launch allows the training to stay fresh. This group should establish the objectives for the training, determine the agenda and develop a training schedule with the goal of all RNs are trained within 30days of the template implementation. A decision should be made to insure the training is without distraction by seeing that all staff are trained off the unit. This key decision must be supported by the Nurse Executive.

79. Let�s look at an Overview of the training 79 This section of the presentation is an overview of the training as presented to staff in Western New York. The actual first part of the launch came immediately after the training each nurse received. She/he was expected to return to their unit and start using the new template. At the end of the month of training all nurses working in inpatient areas were expected to be using the templates. This section of the presentation is an overview of the training as presented to staff in Western New York. The actual first part of the launch came immediately after the training each nurse received. She/he was expected to return to their unit and start using the new template. At the end of the month of training all nurses working in inpatient areas were expected to be using the templates.

80. Agenda for 60 minute training Objectives of the training and using the national templates Review Guidelines on what & when to use templates A Falls Prevention PowerPoint Presentation Review of the VANOD Fall Risk Assessment and Review of VANOD Post Fall Note Templates by PowerPoint 80 The final, 60 minute session, included: the objectives of the training and objectives in moving to the use of the national templates, guidelines on what template to use & when, a Falls Prevention PowerPoint presentation, a review of VANOD Fall Risk Assessment and Post Fall Note Templates. (Note this was a PowerPoint presentation may be chosen over a live demo in CPRS to prevent getting bogged down in navigational issues thru the templates.) The final, 60 minute session, included: the objectives of the training and objectives in moving to the use of the national templates, guidelines on what template to use & when, a Falls Prevention PowerPoint presentation, a review of VANOD Fall Risk Assessment and Post Fall Note Templates. (Note this was a PowerPoint presentation may be chosen over a live demo in CPRS to prevent getting bogged down in navigational issues thru the templates.)

81. Training agenda continued Set up new VANOD templates in each nurse�s folder Brief overview of VANOD ProClarity Data Reporting via website Emphasis on Resident Safety in Comfort Care Rounds Using a new form for the Community Living Centers Reviewed our local policies and procedures Quiz to validate learning, they kept it for reference In-service Evaluation form completed, CEU given 81 Including the new VANOD templates in each nurse�s preferred note titles folder and deleting any local templates being used can help nurses remember to use the new templates. A brief overview of VANOD ProClarity Data can be presented via a quick trip out to the live website. The transition to a new focus on Patient and Resident Safety rather than the traditional Comfort Care Rounds should be discussed. If new local policies are put in place these should be reviewed regarding charting falls in CPRS , in Vista via the incident report and the use of the new national VANOD fall templates showing that the new guidelines for using the templates had been incorporated into the policy and procedure. Utilize a quick quiz to validate key concepts learned. Nurses can keep the quiz for reference for later reference. Including the new VANOD templates in each nurse�s preferred note titles folder and deleting any local templates being used can help nurses remember to use the new templates. A brief overview of VANOD ProClarity Data can be presented via a quick trip out to the live website. The transition to a new focus on Patient and Resident Safety rather than the traditional Comfort Care Rounds should be discussed. If new local policies are put in place these should be reviewed regarding charting falls in CPRS , in Vista via the incident report and the use of the new national VANOD fall templates showing that the new guidelines for using the templates had been incorporated into the policy and procedure. Utilize a quick quiz to validate key concepts learned. Nurses can keep the quiz for reference for later reference.

82. The two new National VANOD Falls templates Objectives of the training declared that: Each RN at the completion of the training will know how and when to complete a: Fall Risk Assessment and Post Fall Note using the new National VANOD Fall Risk templates 82 Each RN at the completion of the training, should know how and when to complete the new VANOD National Fall Risk Assessment and Post Fall Note template. Each RN at the completion of the training, should know how and when to complete the new VANOD National Fall Risk Assessment and Post Fall Note template.

83. Expected Outcomes Each RN will know the effective use of the Morse Fall Scale use and �Safety Comfort Rounds� form in use on each unit, and will be refreshed on the S.A.F.E. (Staff against Falls Everywhere) center guidelines, and knowledge about fall prevention in general. The recent Fall Root Cause Analysis (RCA) Action Plan was addressed in this training: transitioning comfort rounds into safety and comfort rounds. 83 A review of the Morse Scale is useful to assure consistent scoring throughout the facility. Problem areas may include consistency in the history of falls, the secondary diagnosis and the question about how alert and oriented the person is. Reviewed any Root Cause Analysis findings and proposed action plans involving the goal of trying to reduce the number of major injuries at your health system and incorporate those findings in the implementation strategy. The Safety aspect of the comfort rounds was stressed. Remind RNs on the Staff against Falls Everywhere Program and the center memorandum on Falls Prevention. A review of the Morse Scale is useful to assure consistent scoring throughout the facility. Problem areas may include consistency in the history of falls, the secondary diagnosis and the question about how alert and oriented the person is. Reviewed any Root Cause Analysis findings and proposed action plans involving the goal of trying to reduce the number of major injuries at your health system and incorporate those findings in the implementation strategy. The Safety aspect of the comfort rounds was stressed. Remind RNs on the Staff against Falls Everywhere Program and the center memorandum on Falls Prevention.

84.  Guidelines for Using the VANOD FALL RISK ASSESSMENT NOTE [T] V2 and POST FALL NOTE [T] V2� For Acute Care patients: At admission complete Fall Risk Assessment Note Every 48 hours complete Fall Risk Assessment Note � Transfer complete Fall Risk Assessment Note (completed by receiving unit) After a fall complete the Post Fall Note � At Discharge complete Fall Risk Assessment 84 Here are some guidelines for using the templates in the acute care setting. Here are some guidelines for using the templates in the acute care setting.

85. Guidelines for Using Templates For Community Living Center Residents: At admission Use Fall Risk Assessment � Weekly for first 4 weeks Use Fall Risk Assessment Transfer to another unit Use Fall Risk Assessment (By Receiving Unit) After a fall Use Post Fall Note Annually Use Fall Risk Assessment At Discharge Use Fall Risk Assessment 85 These guidelines are for community living centers. These guidelines are for community living centers.

86. 86 This logo was used to help raise awareness of fall prevention during the launch campaign. The artwork for this logo and the slogan were developed by Dr. McDonnell, Geriatric physician, and Dave Ebling, data specialists. This logo was used to help raise awareness of fall prevention during the launch campaign. The artwork for this logo and the slogan were developed by Dr. McDonnell, Geriatric physician, and Dave Ebling, data specialists.

87. 87 Nursing Actions and Interventions: Become familiar with the Safe Patient Handling policy and procedure Remind patients to ask for help during Safety/Comfort rounds Keep all commonly used items, like the telephone, call light, walking aids, glasses and water within reach Keep bed in the lowest position when occupied or exiting Offer to assist with toileting on comfort rounds Use handrails in bathrooms Consider high toilet seat Wear non-skid footwear Lock wheelchairs & beds Use available & appropriate lift equipment Watch for wet spots on the floor Make sure room is well lit Displayed here are the common nursing Actions and Interventions that are taken to prevent falls. Displayed here are the common nursing Actions and Interventions that are taken to prevent falls.

88. 88 Encouraging Staff Participation We Invited the RNs to join the falls committee Want to help, but not be a member? Other Opportunities exist for interested parties: to help plan and participate in the annual Fall Prevention Fairs Invite your RNs to join the Falls Committee or help out in other ways such as the annual Falls Prevention Fairs that we put on at each facility. Invite your RNs to join the Falls Committee or help out in other ways such as the annual Falls Prevention Fairs that we put on at each facility.

89. VANOD Fall Risk Template 89 VANOD Fall Risk Assessment (T) V2 template Review the templates in detail to familiarize staff with them. Mention things that might be possible pitfalls such as inconsistent scoring from one nurse to another. Review the time needed to complete each template. The appearance of additional time added is a concern for most staff members. When experienced in the use of these templates it should take staff only a couple of minutes to complete them. Be sure to include the union as to this implemention as they will be concerned if there is a perception of adding to the workload of the RNs. Review the templates in detail to familiarize staff with them. Mention things that might be possible pitfalls such as inconsistent scoring from one nurse to another. Review the time needed to complete each template. The appearance of additional time added is a concern for most staff members. When experienced in the use of these templates it should take staff only a couple of minutes to complete them. Be sure to include the union as to this implemention as they will be concerned if there is a perception of adding to the workload of the RNs.

90. VANOD Fall Risk Template 90 On the Fall Assessment template focus on the Morse Scale and individualizing interventions to meet each unique veteran�s needs. On the Fall Assessment template focus on the Morse Scale and individualizing interventions to meet each unique veteran�s needs.

91. 91 Looked at the Post Fall Note template in detail and pay special attention to the notification section. Looked at the Post Fall Note template in detail and pay special attention to the notification section.

92. VANOD Post Fall Note Template 92 Those notified when a fall takes place depends each site�s policies and on the shift, the unit, location and the severity of the injury from the fall�. Each facility may have a different protocols. Be sue to review them during training. Those notified when a fall takes place depends each site�s policies and on the shift, the unit, location and the severity of the injury from the fall�. Each facility may have a different protocols. Be sue to review them during training.

93.  Let�s look at The Impact and Nursing Outcomes 93 In this section the impact that this template use has had on Nursing Outcomes will be discussed. The data at WNY shows that the use of these new templates has made a difference leading a positive outcome. Here is a look at how data is collected, sorted, sliced and reported. In this section the impact that this template use has had on Nursing Outcomes will be discussed. The data at WNY shows that the use of these new templates has made a difference leading a positive outcome. Here is a look at how data is collected, sorted, sliced and reported.

94. Post training actions to ensure success Reinforcement by the Nurse Managers and the Clinical Nurse Leads Tracers by the VANOD Site Coordinator Coaching by reminder emails Mentoring 1 to 1 with non compliant nurses Monthly Fall Committee meetings Monthly review and use of the data Update Falls Policies and Procedures 94 Take actions post training to ensure success. Include encouragement and reinforcement by the Nurse Managers and Clinical Nurse Leads to use the templates timely and properly. Tracers can be conducted on each unit for the entire month after the formal training and ongoing on a periodic basis may be used. Coaching by using reminder emails to all RNs using the templates in the form of VANOD Fall Tip of the Month, mentoring 1 to 1 in the case of noncompliance, sharing data reports at monthly Fall Committee meetings are useful approaches to take. Falls Policies and Procedures should be updated to include the use of the new Falls templates. A monthly Fall template refresher course for new and nurses identified as needing charting improvement cam be helpful as well. Fall Prevention Coordinator reviews of every fall with the staff on the unit is a useful approach at WNY. Reviewing the initial fall assessment made in the ER on every veteran who arrives at the hospital by Ambulance and comparing it with the initial admission fall assessment on the units is another way of validating consistency in charting. Take actions post training to ensure success. Include encouragement and reinforcement by the Nurse Managers and Clinical Nurse Leads to use the templates timely and properly. Tracers can be conducted on each unit for the entire month after the formal training and ongoing on a periodic basis may be used. Coaching by using reminder emails to all RNs using the templates in the form of VANOD Fall Tip of the Month, mentoring 1 to 1 in the case of noncompliance, sharing data reports at monthly Fall Committee meetings are useful approaches to take. Falls Policies and Procedures should be updated to include the use of the new Falls templates. A monthly Fall template refresher course for new and nurses identified as needing charting improvement cam be helpful as well. Fall Prevention Coordinator reviews of every fall with the staff on the unit is a useful approach at WNY. Reviewing the initial fall assessment made in the ER on every veteran who arrives at the hospital by Ambulance and comparing it with the initial admission fall assessment on the units is another way of validating consistency in charting.

95. Posted on all units RNs should now be using the national VANOD Fall Risk Assessment Note [T] V2 on admission and the Post Fall Note [T] after all falls (No longer using local fall risk templates!) 95 A poster such as this one can be posted on all units to remind the staff to use the templates. A poster such as this one can be posted on all units to remind the staff to use the templates.

96. Sharing the Information Falls Committee VANOD Committee Nurse Manager monthly meetings 96 Share the information about use of the VANOD templates with the Falls and VANOD Committees and at any Monthly Nurse Manager meetings that your Nurse Executive may have scheduled at your facility. The support of VANOD template by the Nurse Executive is paramount. We have the support of ours in WNY! Share the information about use of the VANOD templates with the Falls and VANOD Committees and at any Monthly Nurse Manager meetings that your Nurse Executive may have scheduled at your facility. The support of VANOD template by the Nurse Executive is paramount. We have the support of ours in WNY!

97. Looking at the results 97 The data supports the program WNY is glad to share the following sample of the outcomes data they use each month to track trends, refocus and make adjustments to ensure that the culture of fall prevention stays fresh and remains an integral part of day to day nursing care.WNY is glad to share the following sample of the outcomes data they use each month to track trends, refocus and make adjustments to ensure that the culture of fall prevention stays fresh and remains an integral part of day to day nursing care.

98. 98 This is a screen shot of the entry screen of the program that is used to create the local database. This captures fall data elements and will continue to be used until a full national roll out is provided by VANOD and VSSC. At that time it is anticipated the fall data collected from the template use will be reported in ProClarity just as the skin data is at this time. This is a screen shot of the entry screen of the program that is used to create the local database. This captures fall data elements and will continue to be used until a full national roll out is provided by VANOD and VSSC. At that time it is anticipated the fall data collected from the template use will be reported in ProClarity just as the skin data is at this time.

99. 99 This is a screen shot of the WNY Patient Fall tracking Workbook, accessible by our Executive team the Nurse Managers, and reviewed each month at the Falls Committee meetings. It is prepared by our Performance Management Group. This workbook is updated monthly with count and rate data and posted on a public drive so staff with access can avail themselves of the data results. This includes the MVAC, GEC, and BVAC inpatient area and the Home based Primary Care outpatient program. The focus is the number of total falls and the falls causing major injuries to our veterans. This is a screen shot of the WNY Patient Fall tracking Workbook, accessible by our Executive team the Nurse Managers, and reviewed each month at the Falls Committee meetings. It is prepared by our Performance Management Group. This workbook is updated monthly with count and rate data and posted on a public drive so staff with access can avail themselves of the data results. This includes the MVAC, GEC, and BVAC inpatient area and the Home based Primary Care outpatient program. The focus is the number of total falls and the falls causing major injuries to our veterans.

100. 100 WNY looks back at data for an ongoing 24 month period with new data added each month. Here is a sample of the format in which we report the numbers and our use of trend lines. WNY looks at trends and spikes in trends for each and every unit both from the numbers vantage point and the trend line graphs. The unit identifier has been eliminated from these slides for confidentiality. WNY looks back at data for an ongoing 24 month period with new data added each month. Here is a sample of the format in which we report the numbers and our use of trend lines. WNY looks at trends and spikes in trends for each and every unit both from the numbers vantage point and the trend line graphs. The unit identifier has been eliminated from these slides for confidentiality.

101. 101 Managers look for trends and outlier points like the fall rate in 11/2009. Data that signals a need for drill down by the unit nurse manager. Managers look for trends and outlier points like the fall rate in 11/2009. Data that signals a need for drill down by the unit nurse manager.

102. 102 This is an example of a drill down of falls on a particular unit sorted by shift in response to the 11/2009 outlier to see which shift is responsible for the spike and why. This is an example of a drill down of falls on a particular unit sorted by shift in response to the 11/2009 outlier to see which shift is responsible for the spike and why.

103. 103 In this example further drill down is done by hour due to the spike in third shift falls. Note that between 4pm and 6pm there were 6 falls. More than any other consecutive 3 hours in 11/2009 for example. These data are provided to unit team to assist in formulating a response to the data signal. The nurse manager is given 30 days to prepare a PIA which is a Performance Improvement Plan and report this plan back to the Falls Committee at the next monthly meeting. This report also shows the highest number of falls occurs at 1700 (5 PM) when dinner trays are being served, what does that tell you? In this example further drill down is done by hour due to the spike in third shift falls. Note that between 4pm and 6pm there were 6 falls. More than any other consecutive 3 hours in 11/2009 for example. These data are provided to unit team to assist in formulating a response to the data signal. The nurse manager is given 30 days to prepare a PIA which is a Performance Improvement Plan and report this plan back to the Falls Committee at the next monthly meeting. This report also shows the highest number of falls occurs at 1700 (5 PM) when dinner trays are being served, what does that tell you?

104. VANOD Fall Risk national templates were implemented in January of 2009 and have been in use since Fall Data Analysis FY 2008 there were 815 inpatient falls with 19 major injuries for a major injury rate of 2.3%. FY 2009 there were 832 falls with a total of 15 major injuries, making the major injury rate 1.8%. This is an improvement over the previous year FY 2010 so far year to date continues to show major decreases 104 At WNY VANOD Fall Risk national templates were implemented in January of 2009 and have been in use since with good results. Our Fall Data Analysis shows that In Fiscal Year 2008 there were 815 inpatient falls with 19 major injuries for a major injury rate of 2.3%. In Fiscal Year 2009 there were 634 inpatient falls with 15 major injuries for a major injury rate of 1.8%. This is an improvement over the previous year allowing us to meet the Nursing Outcomes objective When January, February, March 2010 data were compared with the previous three months October, November, December 2009 Inpatient Total falls per 1000 Bed Days Of Census decreased by 24% compared to the previous period Major injuries overall decreased 50% compared to the preceding period Minor injuries overall decreased 39% compared to the preceding period. � BVAC Trends showed Major injuries had no change and remained at zero, Minor injuries increased 200% (but only from 0 to 2) Total falls decreased .05% our MVAC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 36% Total falls decreased 34% � and GEC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 52% Total falls decreased 22% This is the best single quarter improvement in decreasing fall trends ever seen in WNY. At WNY VANOD Fall Risk national templates were implemented in January of 2009 and have been in use since with good results. Our Fall Data Analysis shows that In Fiscal Year 2008 there were 815 inpatient falls with 19 major injuries for a major injury rate of 2.3%. In Fiscal Year 2009 there were 634 inpatient falls with 15 major injuries for a major injury rate of 1.8%. This is an improvement over the previous year allowing us to meet the Nursing Outcomes objective When January, February, March 2010 data were compared with the previous three months October, November, December 2009 Inpatient Total falls per 1000 Bed Days Of Census decreased by 24% compared to the previous period Major injuries overall decreased 50% compared to the preceding period Minor injuries overall decreased 39% compared to the preceding period. � BVAC Trends showed Major injuries had no change and remained at zero, Minor injuries increased 200% (but only from 0 to 2) Total falls decreased .05% our MVAC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 36% Total falls decreased 34% � and GEC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 52% Total falls decreased 22% This is the best single quarter improvement in decreasing fall trends ever seen in WNY.

105. So far in 2010 The following information compares January, February, March 2010 with the previous three months October, November, December 2009 � IP Total falls/1000BDOC decreased by 24% compared to the previous period Major injuries overall decreased 50% compared to the preceding period Minor injuries overall decreased 39% compared to the preceding period. � � BVAC Trends: Major injuries showed no change (0) Minor injuries increased 200% (from 0 to 2) Total falls decreased .05% MVAC Trends: Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 36% Total falls decreased 34% � GEC Trends: Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 52% Total falls decreased 22% � 105 To recap and summarize: The VANOD Fall templates were implemented in January of 2009 and have been in use since. When we compared January, February, March 2010 with the previous three months October, November, December 2009 we � Inpatient Total falls per 1000 Bed Days Of Census decreased by 24% compared to the previous period Major injuries overall decreased 50% compared to the preceding period Minor injuries overall decreased 39% compared to the preceding period. � BVAC Trends showed Major injuries had no change and remained at zero, Minor injuries increased 200% (but only from 0 to 2) Total falls decreased .05% our MVAC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 36% Total falls decreased 34% � and GEC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 52% Total falls decreased 22% This is the best single quarter improvement in decreasing fall trends that we have ever seen. To recap and summarize: The VANOD Fall templates were implemented in January of 2009 and have been in use since. When we compared January, February, March 2010 with the previous three months October, November, December 2009 we � Inpatient Total falls per 1000 Bed Days Of Census decreased by 24% compared to the previous period Major injuries overall decreased 50% compared to the preceding period Minor injuries overall decreased 39% compared to the preceding period. � BVAC Trends showed Major injuries had no change and remained at zero, Minor injuries increased 200% (but only from 0 to 2) Total falls decreased .05% our MVAC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 36% Total falls decreased 34% � and GEC Trends showed Major injuries decreased 50% (from 2 to 1) Minor injuries decreased 52% Total falls decreased 22% This is the best single quarter improvement in decreasing fall trends that we have ever seen.

106. Data Summary and Conclusions The number of major injuries in our facility is low Four of our major injuries were hip fractures According to literature, hip fractures cost an additional $17,000 to $20,000 per patient �.that constitutes $72,000 to $80,000 related to our facility in FY 2009. Use of the VANOD templates and a focus on preventing falls and a culture of awareness saves countless veterans from falling and enduring the related life changing experiences. 106 In conclusion, although the number of major injuries in our facility is in reality low per 1000 BDOC we still had four. All four of the major injuries were hip fractures. According to literature, hip fractures cost an additional $17,000 to $20,000 per patient �.that constitutes $72,000 to $80,000 related to our facility in FY 2009. Use of the VANOD templates and a focus on preventing falls and a culture of awareness saves countless veterans from falling and enduring these expenses and these very harsh life changing experiences. The four fewer we had in this time period many have all been major hip fracture injuries. In conclusion, although the number of major injuries in our facility is in reality low per 1000 BDOC we still had four. All four of the major injuries were hip fractures. According to literature, hip fractures cost an additional $17,000 to $20,000 per patient �.that constitutes $72,000 to $80,000 related to our facility in FY 2009. Use of the VANOD templates and a focus on preventing falls and a culture of awareness saves countless veterans from falling and enduring these expenses and these very harsh life changing experiences. The four fewer we had in this time period many have all been major hip fracture injuries.

107. Celebrate your successes Data that validates or changes our behavior is useful data! 107 Use your data for improvement, and celebrate your successes! Use your data for improvement, and celebrate your successes!

108. We do it for our Veterans � Our heroes 108 We do it for our Veterans � Our heroes! We do it for our Veterans � Our heroes!

109. Contact Information Thank you! Kim Fitz, RN Virginia.Fitz@va.gov Jennifer Batt, RN, BSN, MBA Jennifer.Batt@va.gov 109 Contact us with questions. Thank you for your attention. Contact us with questions. Thank you for your attention.

110. Questions? 110