Fall Prevention Deserves Your Attention: How Johnson City ... Fall...Using Lean Tools to Generate...
Transcript of Fall Prevention Deserves Your Attention: How Johnson City ... Fall...Using Lean Tools to Generate...
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Fall Prevention Deserves Your Attention: How Johnson City Medical Center Reaches Root Cause
May 17, 2019
Jennifer Stuart, MBA, BSN, RN
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Today’s Objectives
1. Facility Overview
2. Understand Reason for Action & Initial State Opportunities
3. Fall Drilldown Process
4. Fall Prevention Process Strategies
5. Case Study
May 17, 2019 Presentation Title2
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Johnson City Medical Center
May 17, 2019 Presentation Title3
Johnson City Medical Center
Licensed Beds: 501
Outpatient visits: 263,523
ED visits: 60,496
Average program LOS: 4.97
Average daily census: 328
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Johnson City Medical Center
• Level 1 Trauma Center
• Comprehensive Stroke Center
May 17, 2019
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Reason for Action & Initial State Opportunities
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We were experiencing issues relating to:1. High rate of falls2. Underutilization of tools3. Accountability4. Sustainment Opportunities 5. Lack of standardization
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May 17, 2019 Presentation Title6
Initial State
• Unassisted Falls/ Assisted Falls FY Comparisons • Physiological related opportunities
• Medications /Altered mental status/Psych• Bathroom related opportunities
• Patients left alone• Failing to call for help
• Bed Alarm opportunities• Utilization • Notification of alarms to the staff
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Target State
May 17, 2019 Presentation Title7
• Dismiss the myths• Reach the root cause by asking the right questions• Trend across the board for facility and units• Determine sustainable fall prevention tools• Gather a committee with various stakeholders• Process for drilling down and reporting• Standardization• Accountability• Create heightened awareness & culture shift
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May 17, 2019 Presentation Title8
Using Lean Tools to Generate the Focus
• Visual Management• Pareto Charts – “Let the data tell the story”
• Majority of falls:• Tuesdays and Saturdays• 1p-7p• Involved seasoned staff
• Root Cause• Countermeasures• Standard Work
- Drilldown Tool for Nurse Managers- Weekly Fall Summary Tool - Monthly Fall Summary Recap Tool
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Fall Drilldown Process – Weekly
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• Reserved time• Leadership & frontline staff• Completed Drilldown Preparation• Present Fall• Discuss root cause• Committee reviews• Discuss trends• List Countermeasures and educational opportunities• Celebrate wins
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Fall Prevention Process – Committee
May 17, 2019 Presentation Title10
• Review previous weeks falls totals and trends• Discuss opportunities • Review Vols for Falls prevention prior results• Discuss opportunities from the audit• Review prior weeks countermeasures• Discuss action items from the above reviews• End of month summary review• Algorithm usage/feedback
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Case Study
May 17, 2019 Presentation Title11
What We LearnedProcess• Reviewed situation at hand• Manager consulted with fall
committee• Determined patient could benefit
from one of our fall risk tools (enclosure bed)
Challenge
• 84 year old male. Altered Mental Status, history offalls at home ,impulsive patient with dementia
• Night shift nurse “ camped” in front of room redirecting him• Day-shift nurse reported at boards ”This patient will fall”
• Needed better education on our tools available
• Appropriate escalation• Patient benefited, decreased
LOS, no sedation meds, patientcalmed
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Case Study
May 17, 2019 Presentation Title12
What We LearnedProcess• Reviewed situation at hand• Manager consulted with fall
committee• Determined the manager
needed to have a conversationwith patient and family
Challenge
• 68 year male with cancer, just received the news from physician“There is nothing else we can do”
• Patient had fallen the previous night and was still refusing all fall precautions
• Ask better questions • Loss of Independence has to be
considered • Make the situation a “win-win”
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May 17, 2019 Presentation Title13
Fall Prevention Strategies & Drilldown Discoveries
Gaps:• Ancillary departments had limited understanding of bed functionality• Beds not working properly• Varying levels of accountability
Solutions:• Educators to help provide education to ancillary departments• Nursing work order request education• Standardized Action Plans for consistent accountability
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May 17, 2019 Presentation Title14
Fall Prevention Process – Vols for Falls• University of Tennessee Volunteers for Falls• 15 Fall Prevention Champions / Volunteers• Training• Auditing Tool • Real Time Feedback
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Celebrations!
May 17, 2019 Presentation Title15
• 29% reduction in bathroom related falls
• 12% reduction in physiological related factors
• 30% of our units have been fall free since February
• 2 units have been fall free since September and November
• % of Improvement per Unit this FY:
• Projected to surpass the average assisted fall rate this FY
2200(13 falls to 9) 30.77%
2300(14 falls to 7) 50%
2700(10 falls to 2) 80%
4200(28 falls to 11) 60.71%
4300(27 falls to 9) 66.67%
6400(19 falls to 14) 26.32%
6500(7 falls to 3) 57.14%