Join the Falls Prevention Virtual Learning Collaborative
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Transcript of Join the Falls Prevention Virtual Learning Collaborative
Join the Falls Prevention Virtual Learning Collaborative
Falls Virtual Learning Session # 4 & Closing Congress Team Rapid Fire Presentation Template
Cross Cancer Institute, Edmonton, Alberta
Amy Kantor, Quality Consultant
Edmonton, Alberta
Ambulatory and Inpatient Care• 3 inpatient units• ~56 beds• ~140 RN’s plus NA’s, PT, OT, RT, Pharmacists and
MD’s
Primary Cancer Care facility, serving all of northern Alberta.
Who We Are
Team Members
Team Member Role
Nadia Kloc Inpatient Nurse Manager
Carolyn Howe-Riddell Inpatient Resources Nurse
Carole Szwajkowski Nursing Education
Judy Poon Rehab Medicine,Physiotherapy
Amy Kantor Quality Consultant
AIM
To lead and coordinate team learning, process and care improvements; to ensure our targeted goals are achieved in falls and injury reduction and that we contribute as active participants in the SHN Falls Prevention VLC.
• Reduce incidence of falls (fall rate) by 40% from baseline (to 2.4%) by March
2011.
• Reduce injury from falls by 40% from baseline (to 19%) by March 2011.
• Scope: Inpatient units (3 units, 56 beds)
Change Ideas
Changes tested during Falls VLC PDSA Cycles:
Implementation of an appropriate Assessment Tool• Initially used Schmidt tool, now working with Morse tool
Inventory of mobilization equipment and aids and storage locations• Discovered shortage of transfer belts, purchasing more and moving to a more
visible and accessible storage location
Evaluate location of majority of falls (~60% occur in the bathroom)• Planning to trial bathroom signs encouraging patients to call for assistance
Implementation of a Post-Falls Assessment Tool• Trialing and revising a tool to help discover specific reasons for falling
Implement an apple as a symbol for a patient at risk of falling• To be placed outside of patients room, used for recognition and promotional
‘materials’
Measures1: Falls Rate per 1000 Patient Days
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
Month
Fa
lls/1
00
0 d
ay
s
Fall Rate 4.74 3.71 3.29 3.90 4.46 2.00 3.29 2.58 2.76 2.48 3.00
Goal 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40 2.40
Apr2010
May2010
Jun2010
Jul2010
Aug2010
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Implemented Risk Assessment
Number of Falls per Month
Range: 4-7
Mean: 5
Change in Event Reporting System
MeasuresPercentage of Falls Causing Injury
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Month
Pe
rce
nta
ge
of
Ha
rmfu
l Fa
lls
CCI Data 14.3% 33.3% 60.0% 0.0% 42.9% 60.0% 80.0% 25.0% 50.0% 50.0% 50.0%
Goal 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0% 19.0%
Apr2010
May2010
Jun2010
Jul2010
Aug2010
Sep2010
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Implemented Risk Assessment
Number of Falls Causing Injury per Month
Range: 0-4
Mean: 2
Change in Event Reporting System
MeasuresPercentage of Completed Fall Risk Assessment on Admission
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Month
Pe
rce
nta
ge
CCI Data 66.2% 81.7% 83.3% 82.4% 87.5%
Goal 100% 100% 100% 100% 100%
Oct2010
Nov2010
Dec2010
Jan2011
Feb2011
Number of Charts Reviewed per Month
Range: 54-82
Mean: 67
Lessons LearnedLessons Learned/Key Insights
Slow and steady wins the race
Buy in from staff is essential to success
Important to understand the foundation of the concept first
The right tool is needed: take the time to find it, don’t be afraid to change it
Follow through is required and it needs to be consistent
Ongoing compliance monitoring is key to maintaining gains
Changes to our event reporting system just prior to implementation may have affected our data
We’re still learning!
• Champions emerged from Physiotherapy department Data collection became easy with their help
• SHN Virtual Learning Series taught the team about: Quality improvement methodology (Can be applied to other projects) Data collection, analysis and trending Viewing the issue from a broader perspective: i.e. pharmacology,
special considerations for the elderly, etc. • Great connections made between departments
(Nursing, Education, Physiotherapy, Quality)• Great ideas to build on from other teams in the collaborative
Quick Wins
Next Steps
Key Sustainability Steps/Plan: Target Dates
Decide on an assessment tool 1 month
Implement bathroom signs 1 month
Finalize post falls assessment tool and decide if it is going to be used
Next 2 months
Roll out education to the staff (serve apple treats to generate recognition)
1 month
Launch the apple symbol 1 month