Fall Prevention Utilizing Six Sigma Methodologies to Improve Patient Outcomes Presented by:...

Fall PreventionUtilizing Six Sigma Methodologies to

Improve Patient Outcomes

Presented by: Virtua’s Fall Prevention Team

What is Six Sigma?… Methodology for achieving goals

and objectives Quantitative technique for problem

solving Comprehensive improvement

processTools For Driving Sustainable Change

...what are we measuring; know our measure is good...

… look for root causes; generate a prioritized list of

inputs...

... determine and confirm the optimal solution ...

…be sure the problem doesn’t come back...

... define the problem, clearly and related to our customer...

The DMAIC Methodology

Define

Define Deliverables

DMAIC

A. Develop Team Charter

B. Identify Project Critical to Quality (CTQ’s)

C. Define Process Map

Identify Project Team and Role assignments Describe Project Align with Strategic Imperatives Delineate Timelines Define Scope of Project Identify Business Units Analyze Constraints Assess Project Benefits Identify Project Goal Evaluate Possible Barriers to Success

Team Charter

DMAIC

What first brought this opportunity to the attention of your business?

As of April 2008, CMS no longer provides reimbursement for treatments associated with patient falls. As a result of these falls, there is a potential for increased length of stay, increased mortality and a decrease in the quality of life.

What evidence do you have that it is really an opportunity worthy of attention?

Reducing the risk of patient harm from falls is one of the National Patient Safety Goals. Data analyzed shows erratic fluctuation in overall falls performance metrics, indicating no true reduction in patient falls across the system. Currently, Virtua has no standardized process for preventing, defining, or reporting patient falls.

What will happen if the business doesn't address this opportunity?This initiative challenges hospitals to improve quality measures to improve patient outcomes. Failing to comply will have a negative impact on the culture of patient safety, public reputation and can result in inappropriate reimbursements.

Opportunity Statement

DMAIC

Voice of the Customer (VOC)!

VOC was captured to understand the problemfrom the customers perspective

DMAIC

Patient Admitted Receives falls assessment

Patient Status Identified

(High falls risk or not)

Patient level of cognizance determined

Interventions put into place

Communicate patient status

Ongoing Assessment

Patient Discharged

High Level Process Map

DMAIC

Who Strongly Opposed

COO X

Nursing Admin X

Admissions Dir X

Rec. Therapy X

Diagnostics X

Medical Director’s X

RN’s, MST’s, CNA’s X 0

Opposed Neutral Supportive Strongly Supportive

Stakeholder Analysis

Not all stakeholders are supportive of the initiative…now what?

DMAIC

How it comes together ...At the end of define, we knew:

• Why this project is important.• What business goals the project must achieve to be

considered successful.• Who the key stakeholders are on the project.• What limitations have been placed on this project.• What key process is involved.• What are the customers’ needs and expectations.

DMAIC

Measure

Measure Deliverables

A. Define performance metricsB. Determine customer specifications and defectsC. Identify potential variablesD. Develop data collection planE. Establish process capability

DMAIC

Prioritized Project Y

CTQ: Inpatient falls are below or equal to 3/1000 pt days

CTQ: Inpatient falls are below or equal to 3/1000 pt days

# of inpatient falls

Target: < or equal to 3/1000 pt days

# of inpatient falls

Target: < or equal to 3/1000 pt days

CTQ: 100% accuracy in falls assessment on admission

CTQ: 100% accuracy in falls assessment on admission

Customer Need

What is the right “Y” to measure?

DMAIC

VOC

• Decrease patient falls

• Effective and efficient bed alarms

• Call bells answered in a timely manner

• Standardized falls prevention education process

• All hospital staff proactive with awareness of falls prevention

• High risk patients identified accurately and placed on proper precautions

• Decrease patient falls

• Effective and efficient bed alarms

• Call bells answered in a timely manner

• Standardized falls prevention education process

• All hospital staff proactive with awareness of falls prevention

• High risk patients identified accurately and placed on proper precautions

Patient admitted receives fall assessment

Magenta band placed on patient

Other preventions

(where available) put into place

Sign placed in room for patient to call for help

Two side rails up.Bed in low position.Brake on.

Phone, call light within reach

Golden rod form completed

No further action taken

Yes

No

Ongoing reassessment

VST assessment

Shift to Shift report

Patient discharged

Pt. falls during admission

Call H.P to see patient

Complete occurrence

report

Schedule testing (if necessary)

Call family immediately

Call attending Physician

Call family (at a reasonable hour)

No

Yes

Redo Morse Scale

Change POC

Daily & PRN documentation on nursing flow

sheet

Education/POC documentation

At Risk?

Patient injured?

Patient falls during hospital stay

DMAIC Acute Care

Detailed Process Map

Patient Falls

Assess. Tool Communication

Environment/Other EducationPhysicians

Misinterpretation of Assessment tool

Only 1 tool used in Assessing pt risk

Tracking competency

Process

Morse scale: Bed rest =0

No daily reviewFor mod risk pts.

Lack of hourlyrounding

Untimely D/CPlanning

Infrequent obs.Of pat.

Failure to comm. Pt. Status accurately (Family)

No communication to ptAbout risk

No communication to familyAbout risk

Lack of comm. btwnstaff

Lack of commOn transfers

Family failure toNotify staff on

departure

Staff unawareOf change in status

Lack of knowledgeOf appropriate equip

usage

Review annual competency

Decrease in non-slipfootwear given to

Pts.Checking for recalled

items

No standardized process

Residents unplugging Bed alarms

Placement of tele-Monitors (block call bells)

Tripping hazardsInside pt room

Poor lighting

Failure to notify staff ofDeparture from pt.

room

Unaware ofMorse scale

Category rules

Lack of chart reviews

Lack of safety awareness

No knowledge of falls Prevention program

Clutter in rooms

Mislabeled calllights

Misplacement ofBed pad

Assessment criteria

Patient Falls





Tracking competency

Process










departure



usage




items





Poor lighting


room


Category rules




Clutter in rooms



DMAICInitial

Cause and Effect Diagram

Developed data collection plan Performed “gauge R and R” Developed data collection guidelines Determined acceptable sample size needed for

chart review Performed extensive chart review of all fall

patients

DMAIC

Data Collection

2004 2005 2006 2007 2008

In-patient falls (IPF)

737 617 673 726 717

IPF/1000 BCD (3)*

3.2 3.4 2.6 3.0 2.9

2004 2005 2006 2007 2008550

600

650

700

750



2004 2005 2006 2007 20080

0.5

1

1.5

2

2.5

3

3.5

4

IPF/1000 BCD (3)*

IPF/1000 BCD (3)*

DMAIC

How are we doing?

How it comes together ...

At the end of measure, the team had/knew:

• A list of potential variables• The critical input, process and output measures• The measurement system was accurate• What patterns were exhibited in the data• What the current process capability was

DMAIC

Analyze

Analyze Deliverables

A. Identify variation sourcesB. Establish performance objectives

DMAIC

Patient Falls





Tracking competency

Process












departure



usage




items





Poor lighting


room


Category rules




Clutter in rooms



Assessment criteria

X

C

C

X

X

XC

X

C X

X X

XC

XX

X

X

C

C

C

C X

CX

XX

C C

Patient Falls





Tracking competency

Process












departure



usage




items





Poor lighting


room


Category rules




Clutter in rooms



Assessment criteria

X

C

C

X

X

XC

XC

C X

X X

XC

XX

X

X

C

C

C

C X

CX

XX

C C

X

XX

XLocation in the room

C : Constant = something that doesn’t change

N : Noise = something that adds variability to our Y yet can’t be helped

X : X = a factor that drives our Y

C : Constant = something that doesn’t change

N : Noise = something that adds variability to our Y yet can’t be helped

X : X = a factor that drives our Y

Cause and Effect Diagram

DMAIC

1. Nurses’ interpretation of the Morse Scale

2. Fall score day of fall

3. Medication within 6 hours of fall

4. Patient age

5. Location in room

6. Mental status the day of the fall

7. Orientation on the day of the fall

1. Nurses’ interpretation of the Morse Scale

2. Fall score day of fall

3. Medication within 6 hours of fall

4. Patient age

5. Location in room

6. Mental status the day of the fall

7. Orientation on the day of the fall

ImpactEffort

12 34

5

6

7

DMAIC

Impact/Effort Grid

High/Low

Low/Low

High/High

Low/High

What did we learn from Analyze?

Information collected from chart reviews• Inconsistencies in documentation• Fall score lowered day before fall: 38%• Neuro section of the nursing flow sheet discrepancies: 18%• Patient’s orientation on the day of fall was not reflected in

the scoring of mental status on the Morse scale• No existing documentation on effectiveness of interventions• Confusion with the use and interpretation of the Morse

Scale as an assessment tool• Inconsistent application of the intervention protocol

resulted in patients falling multiple times during their hospital stay

• Lack of documentation supporting changes made to the fall score

*Based on 154 charts reviewed

Change of shift 88% did not fall during shift change Location of fall 82% fell near the bed Day of the week No statistical significance Time of the day No statistical significance LOS No statistical significance

Based on 154 charts reviewed

What did we learn from Analyze?

Survey results

• 77% of Nurses surveyed felt the Morse scale is not an effective assessment tool (Sample: 100)

• 42% of staff surveyed felt that *standard interventions are not effective (Sample:100)

• 36% of staff surveyed felt bed alarms are effective, but the response time is an issue (Sample:100)

• 60% are not aware of the amount of falls occurring on their units (Sample:124)

• 74% are aware of the falls safe program (Sample:124)

*two side rails, magenta (safety) bands

How it comes together ...

By the end of the Analyze Phase, the team was able to show which causes they would focus on in the Improvement Phase by describing:

• Which potential causes they identified • Which causes they decided to investigate and why• What data they collected to verify those causes• How the data was interpreted

DMAIC

Improve

Improve Deliverables

A. Screen Potential Causes*List of Vital Few “X’s”

B. Discover Variable Relationships

*Propose SolutionsC. Establish Operating Tolerances

*Pilot Solution

DMAIC

Root Cause Analysis

Factor Root Cause Proposed Solutions

No standard definitions for falls

Individual processes Standardize falls definitions in alignment with NDNQI

Falls assessment tool (i.e. Morse Scale)

Confusion with interpretation and use

Re-educate staff on the appropriate use. Investigate alternate user-friendly tools

No supporting data for changes made to the Morse scale

Inconsistencies in documentation

Implement best practice from LTC (post-fall assessment)

Missing information in Peminic

No fail safe hard stop enforcing required documentation

Upgrades made to Peminic to include hard stops to enforce required documentation

Inconsistencies in the use of fall interventions

No validation on effective interventions

Pilot improvements on unit with high risk patients and Implement strategic improvement template for consistency

DMAIC

Pre-pilot Activities

The team followed a specific algorithm to complete task in preparation of the pilot.

DMAIC

Findings from Observations

No consistency in interventions used Staff opinions varied on which interventions were

in use No standard process for rounding Many employees were not aware of unit fall rates Most employees had no knowledge of unit action

plans Nurses expressed difficulty interpreting Morse

Scale Patients identified at high risk were not easily

found when reviewing pts charts Fall precautions were not often followed on all

patients identified at risk for falls Staff could not easily identify patients at risk for

falls

DMAIC

Standard Improvement Strategies for Pilot

Educate staff on the process, importance of rounding,

expectations and accountability Educate nurses on the appropriate use of the Morse Scale Consistency in initiating the “4 P’s” during hourly patient

rounds (rounding with a purpose) Post unit results in appropriate (visible) area as a constant

reminder to staff: “how are we doing with patient falls” to

increase staff awareness Consistency in the use of standard interventions (magenta

bands, two bed rails, personal items within reach, bed alarms

(where applicable), falling star, chair alarms (where

applicable) Discuss patients at high risk during morning huddles to

increase awareness* 4 P’s = Pain, Position, Potty (Toileting) and Personal Items

DMAIC

Purpose: Implement improvement strategies while monitoring

performance and effectiveness of process and interventions to reduce preventable falls due to inconsistent practice

Where/Who: 2 nursing units identified with a high volume of patient falls

(4N- Marlton, 4NE Memorial) 4 Members of the fall prevention team would work with staff

to implement improvement strategies, making adjustments as needed

Staff would be surveyed on the perception of the current practice

Timelines: 3/15/10-5/17/10Debrief Sessions: Bi-weekly starting: 3/31/10 (Wednesday’s)

DMAIC

Pilot Plan

Procedures: New procedures documented in SOP format Other materials needed and instructions were developed Staffing: Utilizing existing staffing Fall prevention core team would be available for consultation

purposesStakeholders: Extensive information about pilot was communicated to all

(appropriate) key stakeholders. All involved in the pilot were updated and educated accordingly.Measurements: See attached data collection plan to monitor key indicators. Methods/tools developed to document what works, what doesn’t

and who would respond to unanticipated problems.

Pilot Plan- continued

Metrics Page for Discrete Data

Project Y Target Pre-pilot performance

(1st Quarter ’10)

Post –pilot Performance

(July ‘10)


(Aug ‘10)

# of all patient falls

3.85- fall rate

10 falls3.66- fall rate

1 fall1.03- fall rate

3 fallsTBD-fall rate

Project Y Target Pre-pilot performance

(1st Quarter ’10)


(July ‘10)


(Aug ‘10)

# of all patient falls

3.46- fall rate

10 falls4.11-fall rate



4NE-Memorial

4N-Marlton

Result!

DMAIC

FMEA

Write factual narrative description

Lack of education, knowledge deficit, lack of experience

Potential for repeat fall, inappropriate follow-up, potential to influence disclosure of information

10 Distraction, , dup of documentation

3 Occurrence report follow-up

2 60 Post falls form Team will discuss with Sponsors on: J uly 27, 2010 for next steps and further recommended actions

Schedule testing (if necessary)

Process issue, order not completed apporpriately, poor commun. Hand off, SBAR

Undiagnosed, increase in severity of injury, death

10 Nurse intimidated by physcian esp. at night, no use of SBAR during communication

2 APN / ANM rounds, quality director meetings, occur. Report follow-up

2 40 Units in the red must participate in a mini project similar to falls pilot

Team will discuss with Sponsors on: J uly 27, 2010 for next steps and further recommended actions

Pt. Injured? (YES)

Call family immediately

Contact info. not correct, lack of knowledge, intimidated by family, middle of the night

DOH, or J oint Commission visit, Dissatisfaction (pt./ family) RCA, PCI, Loss of confidence in staff

3 Lack of knowledge, no training on disclosure, info. not captured on admission

7 Occur report, Manager follow-up with nurse

2 42

Action Results

Item / FunctionPotential Failure

Mode(s)Potential Effect(s)

of Failure

Sev

Potential Cause(s)/ Mechanism(s) of

Failure

Prob

Current Design Controls

Det

RPN

Recommended Action(s)

Responsibility & Target Completion

DateActions Taken

New

Sev

New

Occ

New

Det

New

RP

N

FMEA was completed and recommended actions included:

• Implementing rounding with a purpose

• Standardizing system for accountability and follow-through

• Documenting factual narrative description of the event

• Utilizing post falls assessment form

• Discussing falls patients during interdisciplinary rounds

• Including Pharmacy in interdisciplinary rounds once a week

DMAIC

Improve Fall Prevention

Prioritizing the Variables to achieve Six Sigma!

Rounding with a Purpose: Audit tool and SOP’s, Badge Buddies, 4P’s, PCT rounding expectations (with and without clock). Falls will be standing item on unit based council agenda.Post Falls Assessment: Requesting all elements to be available in Peminic.Model under development.

Interdisciplinary Rounds: Daily goal sheet and shift report, encouraged to ask “what level of risk is patient?” instead of “Is patient at risk?”. Mandatory standard use of falling star intervention.

Staff Awareness: Daily and weekly monitoring tool. Falls banner to increase staff awareness.

Fall Education: Redesigned falls (online) education. Fall simulation developed for clinical orientation. Education developed for clinical and non-clinical support service departments

DMAIC

Next Steps for Control

Inform organizational leaders of the changes made to the process

Develop tools needed to sustain improvement (Control plan, SOP’s, Virtual Tool Box, Informational share point sites, etc.)

Communicate changes made to the process to key stakeholders Virtua wide

Educate key stakeholders on the process Virtua wide

Roll out and implementation of improvement strategies Virtua Wide

DMAIC

Questions?

Reducing variation to achieve 6 sigma one defect at a time!

Fall Prevention Utilizing Six Sigma Methodologies to Improve Patient Outcomes Presented by:...

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