rapid fire team presentation

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Rapid Fire Team Presentation Name of Presenter: JoAnn Pelletier-Bressette


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



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



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


Falls Facilitated Learning SeriesCurrent Falls Prevention Program in place:

• Policy• Screening & Intervention Tree• Falls Screening Tool• Falling Leaves – visual tools



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



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):



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



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



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



Validity Study Outcomes



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



Chart Audit Measures

• Process:

– 8 charts audited: all Geriatric patients within the FFLS study group

– Independent auditor used to audit charts



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



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



• 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



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



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



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

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