THE DOWNFALL TEAM PRESENTS…

Multi-Disciplinary Team Peggy Benenati Risk Management Beverly Campbell Nursing Kim Cerri Quality Roberta Farley Physical Therapy Kelli Farnell Pharmacy Ryan Nadeau Nursing Joan Osborne Education

BE ON THE BALL…PREVENT A FALL!

BHIP Fall Stats FY12: 137 Inpatient falls Rate: 3.2 per 1000 patient days 46th percentile

PROBLEM SELECTION AND GOAL

PROBLEM STATEMENT

Hospital Risks

Cost $16,000 per fall 6.27 more days

Falls Increase Risk!

Patient Risks

Sources: The No Fall Zone, Hospital & Health Networks, 6-1-2013; CDC , www.cdc.gov

SIX SIGMA

ROOT CAUSE ANALYSIS AND PROJECT TOOLS

DMAIC Define, Measure, Analyze, Improve, Control

CHARTER

Problem Goal

Business Purpose

Cost

Timeline

Stakeholders CNO Nurse Managers

Communication Plan Project Status Fall reduction is important!

CEO Approval

PROJECT LAUNCH

Process Inputs

Process Suppliers

SIPOC CHART

DEFINE

Process Outputs

High Level Process Steps

Process Customers

PROCESS MAP

MEASURE

DATA PROCESS PROBLEM

DOES THE EXISTING DATA REPRESENT THE PROBLEM?

MEASURE SURVEY

• Random Sample • 45 Nurses • Inpatient Units • All Shifts • Likert Scale • Multiple Choice • Narrative Comments

MEASURE

Incident report fall data reviewed and compiled

Survey data reviewed

and compiled

DATA PROCESS PROBLEM

ANALYZE

Descriptive Statistics • 50% of falls occurred during

bathroom or toileting activities • 20% of patients who fell were

not identified at risk

ANALYZE Survey Data Segmented Stratified Grouped

By • Question • Unit • Shift

Team chose correct answers to measure the survey responses.

INPATIENT FALLS

ANALYZE

ANALYZE Contributing Factors

Incorrect fall risk assessment Lack of identification of patients at risk for falls Inconsistent use of nursing judgment to initiate the fall

prevention protocol Insufficient communication about patients’ fall risk Lack of patient and family participation in the fall prevention

protocol Inconsistent supervision of patients during bathroom and

toileting activities Variable bed alarm functionality

ANALYZE PRIMARY ROOT CAUSE!

Nurses and patients do not fully understand underlying fall risk factors …. …Resulting in critical barriers to appropriate fall risk identification and effective fall prevention.

IMPROVE AND CONTROL

Strategies to improve and sustain process changes Ensure changes are implemented and adopted as routine

IMPROVE

Multifaceted Approach Systematically address each initial root cause Fix the primary root cause! Twofold Intent Enhance nurses’ understanding of fall risk for better identification Enhance patients’ and families’ understanding of fall risk for better

compliance

IMPROVE STRATEGIES

In-depth, comprehensive Physiologic fall risk

factors Weakness, dizziness, fatigue Sensory impairments Mental status Medications

Fall Risk Hand-Off Communication

IMPROVE STRATEGIES

INTRODUCING….

THE ABC’S OF INJURY RISK!

AGE

BONES COAGULATION

SURGERY

IMPROVE STRATEGIES Unit Safety Huddles

High Fall Risk Patients Discussed

Comprehensive Post-Fall Evaluation Tool What did the patient / family say? What were the risk factors? What caused or contributed? Was the patient appropriately assessed? Were appropriate interventions in place? What could have been done to prevent the fall?

On the spot analysis and learning!

IMPROVE STRATEGIES

Fall Prevention Critical Concepts Simple statements about proper assessment and use of the

fall prevention process Example: “A secondary diagnosis is any diagnosis in addition

to the admitting diagnosis.”

IMPROVE STRATEGIES

Aligned with shift-hand off communication Enhance patient participation in fall prevention Fall risk is part of the patient’s medical condition

Scripted Teach Back

IMPROVE STRATEGIES

Scripted Rounding Language

Affirmative statement of intent

Encourage patients to use the bathroom

Example: “I am here to take you to the bathroom.”

IMPROVE STRATEGIES

IMPROVE STRATEGIES

RED RULES

Supervision during toileting activities

Bed alarm activated

Improve Bed Alarm Functionality Connect bed alarms to

Cisco Phones Annual Performance

Maintenance for Bed Alarms Wire bed alarms to ring at nursing stations Environmental Services resets bed alarms after making up

beds

IMPROVE STRATEGIES

Fall Risk Shift Hand-Off

1. Is your patient at risk for fall?

2. What is the Morse Fall Scale score?

3. Has your patient fallen during this hospital stay?

• When did the fall occur and what were the circumstances?

• What were the injuries, if any? • How was POC modified?

4. What physiologic factors contribute to the risk?

• Primary and Secondary Diagnoses that cause weakness, dizziness, fatigue, excessive bed rest.

• Four or more medications associated with falls (CIWA protocol, cardiovascular meds, hypoglycemic agents, psychotropics, muscle relaxants, neuroleptics, opioids, sedatives, sleeping aids, antihistamines).

• What are the medication interactions?

• Does the patient have any symptoms or side effects from medications that would increase risk for falls?

• Mental Status (e.g.: confused, disoriented, combative, doesn’t follow directions, lethargic, somnolent).

• Last time patient was toileted?

• Sensory impairments - (vision, hearing, touch (e.g.: diabetic neuropathy).

• Activity level the prior shift - (stayed in bed, up and out of bed, restless).

5. Is your patient at high risk for injury and why?

• Consider ABCS - Age, Bones, Coagulation, Surgery. • Age—Increased age- higher risk. • Bones- Osteoporosis or other conditions that increase

risk of fracture. • Coagulation- Anticoagulation therapy that increases

risk of bleeding- Coumadin, Pradaxa (this does not include VTE prophylaxis with Lovenox).

• Surgery - Recent surgery that increases risk of injury – hip, knee, abdominal surgery.

6. Recommendations to prevent fall and injury from fall.

IMPLEMENTATION HAND-OFF COMMUNICATION

Hand-off Communication and Teach Back

Team members modeled

hand-off and teach back

Unit fall champions Online education

IMPLEMENTATION

Critical Concepts

Safety Huddles

Rounding

Annual competencies

Unit specific implementation

Rounding initiative and live education

IMPLEMENTATION

Monitor and Sustain Improvements

Falls Committee established as subcommittee of the Nursing Quality and Patient Safety Council

Committee review of data and recommendations for improvement.

Second look in June 2014 – Added laboratory initiative for early morning lab draws.

CONTROL

40 % REDUCTION

Reduced Fall Rate from 3.2 to 1.97 10th Percentile!

SIGNIGICANT COST AVOIDANCE

Consistent communication among the team raises fall risk awareness for better prevention!

Critical thinking is required for accurate fall risk assessment!

LESSONS LEARNED

Communicating reasons for fall risk enhances patient and family participation!

PI project done with intensity and focus is far more effective than PI projected done with urgency!

Successful PI project needs accountability for outcomes among the stakeholders!

What you say to encourage patients to use the bathroom really makes a difference!

The process improvement process is just as important as improving the process!

OUR JOURNEY CONTINUES…