Preventing Falls Utilizing the Targeted Solutions Tool · prevention project using the Preventing...
Transcript of Preventing Falls Utilizing the Targeted Solutions Tool · prevention project using the Preventing...
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opyr
ight
The
Joi
nt C
omm
issi
on
ldquoPreventing Falls Utilizing the Targeted Solutions Toolregrdquo
wwwcenterfortransforminghealthcareorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Objective To help attendees gain a deeper understanding of the work of the Joint Commission Center for Transforming Healthcare high reliability in health care and robust process improvement
To present the Preventing Falls Targeted Solutions Toolreg (TSTreg) methodology and analytical capabilities
To present how one organization implemented a successful falls prevention project using the Preventing Falls Targeted Solutions Toolreg(TSTreg) and achieved significant improvement in all falls and falls with injuries
Click on the hyperlinks to access additional information
Ask questions through the chat box during our QampA session
Interactive Innovative
THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
This webinar is approved for 10 Continuing Education Credit from
Accreditation Council for Continuing Medical Education (ACCME)
Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and
Training (IACET)
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
CECMECEU are available for the live audio only Credits will not be available for webinar replays
In order to claim credits you must have
Individually registered for the webinar through The Joint Commission website
Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only
Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate
Continuing Education Credit
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity
Dawn Glossa MPA Director Corporate Communications The Joint Commission
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare
Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare
Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital
Disclosure Statement
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opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
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opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
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ight
The
Joi
nt C
omm
issi
on
ZERO
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ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
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opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
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The
Joi
nt C
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issi
on
Targeted Solutions
13
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ight
The
Joi
nt C
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on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
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ight
The
Joi
nt C
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issi
on
TST Navigation
27
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ight
The
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nt C
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on
Training Data Collectors
28
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ight
The
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on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
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ight
The
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nt C
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issi
on
Identifying Top Contributing Factors
30
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ight
The
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issi
on
Measuring Outcomes
31
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ight
The
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on
Solutions
32
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The
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on
Solution Guide
33
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ight
The
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on
Action Plan
34
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ight
The
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on
Control Plan
35
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ight
The
Joi
nt C
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on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Objective To help attendees gain a deeper understanding of the work of the Joint Commission Center for Transforming Healthcare high reliability in health care and robust process improvement
To present the Preventing Falls Targeted Solutions Toolreg (TSTreg) methodology and analytical capabilities
To present how one organization implemented a successful falls prevention project using the Preventing Falls Targeted Solutions Toolreg(TSTreg) and achieved significant improvement in all falls and falls with injuries
Click on the hyperlinks to access additional information
Ask questions through the chat box during our QampA session
Interactive Innovative
THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
This webinar is approved for 10 Continuing Education Credit from
Accreditation Council for Continuing Medical Education (ACCME)
Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and
Training (IACET)
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
CECMECEU are available for the live audio only Credits will not be available for webinar replays
In order to claim credits you must have
Individually registered for the webinar through The Joint Commission website
Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only
Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate
Continuing Education Credit
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity
Dawn Glossa MPA Director Corporate Communications The Joint Commission
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare
Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare
Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital
Disclosure Statement
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Objective To help attendees gain a deeper understanding of the work of the Joint Commission Center for Transforming Healthcare high reliability in health care and robust process improvement
To present the Preventing Falls Targeted Solutions Toolreg (TSTreg) methodology and analytical capabilities
To present how one organization implemented a successful falls prevention project using the Preventing Falls Targeted Solutions Toolreg(TSTreg) and achieved significant improvement in all falls and falls with injuries
Click on the hyperlinks to access additional information
Ask questions through the chat box during our QampA session
Interactive Innovative
THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
This webinar is approved for 10 Continuing Education Credit from
Accreditation Council for Continuing Medical Education (ACCME)
Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and
Training (IACET)
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
CECMECEU are available for the live audio only Credits will not be available for webinar replays
In order to claim credits you must have
Individually registered for the webinar through The Joint Commission website
Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only
Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate
Continuing Education Credit
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity
Dawn Glossa MPA Director Corporate Communications The Joint Commission
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare
Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare
Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital
Disclosure Statement
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Click on the hyperlinks to access additional information
Ask questions through the chat box during our QampA session
Interactive Innovative
THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
This webinar is approved for 10 Continuing Education Credit from
Accreditation Council for Continuing Medical Education (ACCME)
Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and
Training (IACET)
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
CECMECEU are available for the live audio only Credits will not be available for webinar replays
In order to claim credits you must have
Individually registered for the webinar through The Joint Commission website
Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only
Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate
Continuing Education Credit
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity
Dawn Glossa MPA Director Corporate Communications The Joint Commission
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare
Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare
Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital
Disclosure Statement
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
This webinar is approved for 10 Continuing Education Credit from
Accreditation Council for Continuing Medical Education (ACCME)
Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and
Training (IACET)
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
CECMECEU are available for the live audio only Credits will not be available for webinar replays
In order to claim credits you must have
Individually registered for the webinar through The Joint Commission website
Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only
Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate
Continuing Education Credit
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity
Dawn Glossa MPA Director Corporate Communications The Joint Commission
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare
Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare
Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital
Disclosure Statement
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
CECMECEU are available for the live audio only Credits will not be available for webinar replays
In order to claim credits you must have
Individually registered for the webinar through The Joint Commission website
Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only
Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate
Continuing Education Credit
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity
Dawn Glossa MPA Director Corporate Communications The Joint Commission
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare
Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare
Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital
Disclosure Statement
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity
Dawn Glossa MPA Director Corporate Communications The Joint Commission
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare
Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare
Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital
Disclosure Statement
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for
Transforming Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Utilizing the Targeted Solutions Toolreg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls Background
Hundreds of thousands of patients fall in hospitals each year
Between 30 to 35 percent of patients who fall sustain an injury
Each of these injuries on average add 63 days to the hospital stay
Cost for a fall with injury is about $14056
10
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
All people always
experience the
safest highest
quality best-value
health care across
all settings
One Vision
11
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Leadership
12
MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Performance Improvement
We have learned fromMajor corporations (for example GE Lilly
BD Cardinal)Extensive experience with 27 hospitals
and systems that use RPI (Joint Commission Center for Transforming Healthcare)
Joint Commission internal experience
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
LeadershipSafety Culture
Robust Process
Improvementreg
FROM LOW TO HIGH RELIABILITY
14
Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
15
Excellence in patient care for every patient every time
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ZERO
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
17
Facilitating Change
Six SigmaLean
ROBUST PROCESS IMPROVEMENTreg
FOCUS IS ON THE PATIENT
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks
ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51
Colorectal SSIs 32Falls with injury rate 62Falls rate 35
Milbank Q 201391459-90J Nurs Care Qual 20142999-102
ROBUST PROCESS IMPROVEMENTreg
18
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
A Systematic Approach for Complex Problem Solving
Define amp measure the impact of the
problem
Discover specific causes
Solutions are targeted to
each specific cause
DEFINE amp MEASURE ANALYZE IMPROVE amp
CONTROL19
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Top Contributing Factors
12
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Targeted Solutions
13
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
ConfidentialSeparate from AccreditationComplimentary
Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread
improvements
14
Preventing Falls
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TSTreg Development Using RPI
Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35
Pilot 7 hospitalsndash Tested and validated methodology
Preventing Falls
15
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Preventing Falls with InjuryImplications of a Robust Approach
200 Bed Hospital
Expect 358 fallsyrndash 117 injuriesndash $17M in costs
Annual impactndash 72 fewer injuriesndash $1M in costs
avoided
16
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Anne Kilpatrick RN BSN CSSBB Black Belt Falls
Project Lead Joint Commission Center for Transforming
Healthcare
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Request Access
If you already have a user name and password click
here
If you do not have a user name and password click
here
26
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
TST Navigation
27
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Training Data Collectors
28
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Data Collection Form
Both Electronic and Paper Form Include ldquoSkip Logicrdquo
20
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Identifying Top Contributing Factors
30
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Measuring Outcomes
31
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solutions
32
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Solution Guide
33
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Action Plan
34
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Control Plan
35
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
27
TSTreg Feedback
Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement
Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
copy C
opyr
ight
The
Joi
nt C
omm
issi
on
Take a Stand Against Patient Falls
37
wwwcenterfortransforminghealthcareorg
or e-mail tst_supporttstorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Beth Neidlinger MSN RN CENP
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
TST Fall Prevention Project Update
Beth Neidlinger MSN RN CENP
March 18 2016
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
About Trinity Mother Frances Hospitals amp Clinics
bull Located in Tyler TX
bull Smith Countyrsquos largest employer
bull One of the highest rated integrated health systems in the United States
bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Project Background
bull Unit Selection
bull Preparation
bull Task Force Role amp Responsibilities
bull Goals
ndash Falls with injury (FWI)
ndash Total Falls
bull Methodology
bull Project status
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Organization Falls Structure
bull Oversight Committee
bull TST Falls Task Force
bull Falls Committee
ndash Quality amp Safety Committee
bull Unit Based Councils
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Organizational Data
Source Center for Transforming Healthcare 332016
Trinity Mother Frances Preventing Falls
4 Dawson
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0939 0000 100000 3443 1241 63956
4 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
2283 0000 100000 7626 3965 48007
5 Ornelas
Baseline Falls wInjury
Improve Falls wInjury
Relative Change Baseline Falls Improve Falls Relative
Change
0744 0263 64651 2975 2630 11597
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Contributing Factors All Falls 4Orn
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Contributing Factors Falls wInjury 4 Orn
bull NO FALLS WITH INJURY SINCE IMPROVE PHASE
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Location All Falls 4Orn
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Injury Level All Falls 4Orn
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Improvement Plan
bull Robust Process Improvement approach
ndash Use of TST Toolkit- linked contributing factors to improvement activities
ndash Enhanced by EBP
ndash Data supported
bull Rapid Cycle Change
ndash UBC driven
bull Pilot persuade promote
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Improvement Activities
bull Assistancecall bell action steps
ndash Purposeful rounding
ndash 5 Prsquos
ndash Hardwiring evidence
bull Rounding audits
bull Staff accountability
ndash Staff contractagreement
ndash Patient contract
bull Toileting
ndash Design program
ndash Scripting
ndash Bedside commodes
ndash ldquoKeep foot in the door to keep your patient off the floorrdquo
ndash Armrsquos reach
ndash White board use
ndash Documentation amp tracking
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Improvement Activities
bull Communication
ndash Data
ndash Staff meetings
ndash Huddles
ndash Falls Hall of FameShame- Bright Ideas Program
ndash Employee recognition-Bright Ideas Program
ndash TMF ldquoMotherboardrdquo with action plans
bull Educationawareness
bull Signage-
ndash RYG (Education UBC project 216)
ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115
bull Hourly rounding focus amp audits- launched 1115
bull Foot in the Door- launched 23 (4 Orn UBC)
bull Toileting protocol- launch 218 (4 D UBC)
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Improvement Activity
A FOOT IN THE DOOR
KEEPS PATIENTS OFF
OF THE FLOOR Preventing falls one patient experience at a time
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Foot in Doorbull Signage
ndash Promotes awareness and aids in education
ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls
ndash Will be placed in sign holders on the door of every room
bull Foot is kept in door of all patients who need to be helped to bathroom
ndash Privacy is maintained but not at expense of safety
ndash Applies to BSC as well
bull No more an arms-reach away from patients
ndash Requires education to ensure that patients know we have their best interests in mind
bull When called to assist other patients
ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member
ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance
bull Goal
ndash Prevent falls during toileting
ndash Promote teamwork and communication amongst the staff
ndash Provide awareness to patients and families
bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Product review
bull Footwear (PT pilot)
bull Gait Belts- all patient rooms to have one
bull Bed-side commodes- all patient rooms to have one
bull Walkers- all patient rooms to have one
bull Chair alarms- in process
bull Fall Mats- in process
bull Other
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg
Next Stepsbull Spread the change
bull Keep pilot units on TST tool ndash sustain the change
bull Add additional units who are still challenged
bull Ongoing reporting
bull Ongoing improvements
bull Celebration Now amp futurehelliphelliphellip
55
QUESTIONS
BethNeidlingertmfhcorg