THE TEAM

1. Diane Lee Matron Emerging Leader Margaret Williams Sponsor Asst DON NWSHA THE TEAM • 4 site acute NHS FT • Elective orthopaedic surgery • Hot site • Day case/ outpatient/rehab • Town centre outpatients site • Population c300,000; ~700 inpatient beds PROJECT AREA To reduce falls by 25% by December 2012 and to improve the patient experience post fall. 27 bedded acute medical ward specialising in gastroenterology. THE TEAM • Falls champion • Quality &Safety Matrons • Sponsor • Ward manager • Matron • AHP • Alcohol liaison nurse • Data analyst • Head of Patient Engagement • Advanced nurse practitioner

2. NHSVanguard Programme The Vanguard Programme enabled me to ….. QUOTE -- “I have increased my knowledge and learned many skills in a supportive way, to enable me to develop anddeliver improvements in patient care”

3. THE BUSINESS CRITICAL PROJECT Cost savings – estimate savings £120,000 per year – direct / indirect. Improve quality of care / NICE guidance post fall. Improve patient experience Provide harm free care as defined by absence of harm from falls in 95% of patients Determine level of harm sustained Link with community services /re- admissions Trust WWL aim to reduce falls by 50% 2011/2013 1,110 in patient falls – 2010/2011 Estimated cost occurred £200,000 per year Number of falls per 7/1000 bed days --- higher than national average Ward Ward has highest number of falls (101) 2010 /2011 No reduction seen in 4 years Average 8.4 falls per month AIM Reduce falls on ward by 25% by Dec 2012 Improve patient experience post fall WHY ? WHAT ? Analysis of data / visual falls map /PDSA cycles Incident reporting / incident completion Staff education / training Assessments / nursing metrics/ Falls champion Staffing review / shift pattern review Falls care bundle Post fall care Partnership working Patient questionnaire /staff questionnaire HOW ? QUIPP

4. THE IMPACT Post fall patient questionnaire implemented Patient comments – “staff were there within minutes” “My Zimmer frame falling onto the floor got the nurses attention” “The fall has knocked me off side” “It has knocked my confidence” “I will use my call bell all the time” “I didn’t want to trouble the nurses” Results Too early to see improvement Dec 11 falls – increase awareness and reporting Jan data 3 falls – normal variance SPC chart Patient questionnaires • Falls Data • In depth analysis of falls in November 2011 • Showed most falls no / low injury • All occurred between hours of 21.00hrs and 07.30hrs • Most occurred at bedside • Majority of patients did not have nurse call bell Changes commenced 12/2011 Intentional rounding Falls champions Staff training MDT meetings Falls care bundle Post falls checklist Diagnostic PDSA PDSA Care bundle Visual falls map Patient stories SNCT Roster review / changes to shift patterns Low profiling bed trial Winning Hearts and Minds Call 2 Action

5. CREATING CONTAGIOUS COMMITMENT TO CHANGE Call 2 Action Public narrative Lone nut video – Practising public narratives Harm free ward leads LEADING CHANGE Developed model for Large Scale Change Framing story Developed discovery model

6. ONWARD SPREAD OF THE LEARNING AND PROJECT Measurement for Improvement PDSA Cycles Vanguard website Seminar recordings Publications C2A Driver Diagram Public Narratives Sustainabilitytool Discovery Model