Rapid Fire Team Presentation
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Transcript of Rapid Fire Team Presentation
www.saferhealthcarenow.ca
Rapid Fire Team Presentation Name of Presenter: JoAnn Pelletier-Bressette
www.saferhealthcarenow.ca
Falls Facilitated Learning Series
Name of Organization: Waypoint Centre for Mental Health Care
Location of Facility: Penetanguishene, Ontario
Number of Patients/Residents/Clients: 312 bed psychiatric facility
Who We Are
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Falls Facilitated Learning Series
AIM
Learn and integrate strategies of sustainability into our organization’s falls improvement plans to ensure we
increase the likelihood of sustaining practice change for prevention of falls and injury reduction while holding the
gains over time
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Falls Facilitated Learning Series
Team Members
Deborah Duncan – VP Regional Programs & Executive SponsorJoAnn Pelletier-Bressette – Nurse Manager Geriatrics & Team LeadDebbie Branch – Occupational Therapist, Dual Diagnosis ProgramKim Dunn – Nurse Educator, Provincial ForensicsMaureen Thornton – Nurse Educator, Concurrent DisordersSherrie Fournier – Patient Safety/QI CoordinatorLee Livingstone - Pharmacist
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Falls Facilitated Learning SeriesCurrent Falls Prevention Program in place:
• Policy• Screening & Intervention Tree• Falls Screening Tool• Falling Leaves – visual tools
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Falls Facilitated Learning Series
Hospital Wide MeasuresWaypoint Centre has been collecting data since November 2010, with all programs reporting on the following four components:
1.Falls rate per 1000/patient days2.Percentage of harmful falls (severity 1-4)3.Percentage of patients with completed falls risk assessment on admission4.Percentage of at risk patients with a falls prevention / protection intervention in place
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Falls Facilitated Learning Series
FFLS Program & Measures
% of falls causing injuryFalls / 1000 patient days
• 8 patients from our Geriatrics Program identified as high risk fallers, used as the FFLS study group• Changes in data not reflective of hospital trends only episodes of falls in the study group• While the study group is not reflective of our total hospital population, the Geriatrics Program is our highest falls risk group
Results (to January 1012):
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Falls Facilitated Learning Series
FFLS Measures
Percentage of "At Risk" Residents with a Documented Falls Prevention/Injury Reduction Plan
Percentage of Residents with Completed Falls Risk Assessment on Admission
No run chart available –at 100% with study group
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Falls Facilitated Learning Series
Review Falls Change Ideas tested to date in your organization
Ideas tested within the Organization
Completed? Facilitators/Barriers identified
Chart Audit/review Completed Yes
Validity Study Completed Yes
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Falls Facilitated Learning Series
Validity Study Measures• Process:
– Four charts selected from three programs
– Following data reviewed:
• Heath care providers admission assessment
• Any referral information from other sources
• Medication prescribed on admission
• “A” form
• Any other information on the file within the first 72 hrs of admission
– Scoring of blank tool completed without knowledge of the actual score recorded on admission
– No record would be kept of actual name or CB number of pt.
– 8 patients already audited on GSP were excluded from tool validation
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Falls Facilitated Learning Series
Validity Study Outcomes
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Falls Facilitated Learning Series
Validity Study Key Findings & Recommendations
Key findings
• 92% of patients had a falls risk screening completed within 72 hrs of admission
• 50% of the time, original assessor/auditors findings fell into the same range. Of these….• 3 out of 11 patients(27%) would not have received interventions for falls risk as one of the 3 falls risk
screening tools completed identified a score within the green range• Difficult to determine if all information was available to original assessor in order to do a complete
assessment
Recommendations:• Regular communication to staff ensuring 100% compliance with policy• Evaluate opportunity for use of a quick screen tool• Collaborative approach to the completion of the falls screen• Clarification on terminology used on screening tool• Communication of findings from validity study related to the compliance and validation processes• Policy update, including completion of screening tool at first clinical
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Falls Facilitated Learning Series
Chart Audit Measures
• Process:
– 8 charts audited: all Geriatric patients within the FFLS study group
– Independent auditor used to audit charts
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Falls Facilitated Learning Series
Chart Audit Key Findings & Recommendations
Key findings
• Kardex main communication tool for visual falling leaf program
• Falls Screening Tool consistently completed inaccurately, including wide range of different items to be scored. However…..
• No one was screened lower than the chart review/tool screened as per data provided. This was great as every patient was a high risk, and did require and receive interventions to reduce risk of falls
• Understanding of scoring the protective factors is not clear
• Fear of falling due to high shine floor
Recommendations:• Provide definition /clarification on each item of the screening tool• Policy update• Review use of gloss finishes on floors
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Falls Facilitated Learning Series
Lessons Learned on Sustaining Falls Improvement Work during Action
PeriodWhat advice would you give to other teams?
• Team commitment to the initiative up front
• Action on the low hanging fruit
• Share successes across the organization
• Learn from other teams’ success and challenges
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Falls Facilitated Learning Series
• What were some barriers?• Competing priorities within the organization leading to time
and resource constraints• Great falls screening process in place – identifying areas of
opportunity
• What are some facilitators?• Strong falls intervention strategies already place• Strong commitment to falls reduction
• How do you propose to move forward?• Refining of the screening tool and policy
Challenges to Sustaining Falls Improvement
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Falls Facilitated Learning Series
6 Month Post FFLS Sustainability Plans for Falls Improvement Work
Goal Description
(What is AIM)
Action
(What STEPS are to be taken to achieve)
Timeframe
(When to be done by)
Person Responsible Metrics: What is to be monitored to identify achievement
Pilot study of Quick Screen Tool
Pilot quick screen on key programsChart audit of completed quick screens during test periodSummary of findings Present to FFLS group.
April 2012 FFLS Team Audit review
Review collaborative approach to completion of screen
Bring forward for discussion at Hospital Wide Risk Review Team Meeting
March/May 2012 Lead, Falls Risk Committee Improvement of Scoring on Follow-up Validation Study
Clarification on screening tool
Develop Definition / Clarification Sheet for items on screening tool
April 2012 FFLS Team Independent Audit Reviews
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Falls Facilitated Learning Series
6 Month Post FFLS Sustainability Plan (continued)
Goal Description
(What is AIM)
Action
(What STEPS are to be taken to achieve)
Timeframe
(When to be done by)
Person Responsible Metrics: What is to be monitored to identify achievement
Floor wax use Review Universal Falls Risk Reduction Strategies: Safe Practice Standards
April 2012 Team Lead, Falls Committee
Upon approval, implement
Policy revision -Modification of policy to reflect above changes(inpatient, outpatient)-Policy review/approval
May , 2012Other dates TBD depending on policy approval/timelines
FFLS Team TBD
Education E-learn RReview/ModificationExplore other educational opportunities
May 2012 FFLS TeamProgram Quality, Risk and Safety Committee Team Leads
Develop standard for yearly review by all clinical staff
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Falls Facilitated Learning Series
Name: JoAnn Pelletier-BressetteEmail: [email protected] Number:705-549-3181 X2116
Or
Name: Sherrie Fournier
Email: [email protected]
Phone Number:705-549-3181 x2787
Contact Information