Join the Falls Prevention Virtual Learning Collaborative

Falls Virtual Learning Session # 4 & Closing Congress Team Rapid Fire Presentation Template

Name of Organization: Hay River Health & Social Services Authority

Name of Speaker: Sheryl L. Courtoreille, Quality Improvement Coordinator

Location of Facility:Hay River Health & Social Services Authority

Hay River, NWT

Number and type of Patients/Residents/Clients:

Who We Are

Number of Patients/Residents/Clients:Acute Care – 19Extended Care – 10Woodland Manor Long Term Care - 15

Team Members

Team Member Role

Alex Simms Occupational Therapist

Jonathan Kennedy Rehabilitation Aide

Becky Boden RN – Home Care

Barb Holland RN – Acute Care

Sue Cullen CEO & Executive Sponsor

Sheryl L. Courtoreille Quality Improvement Coordinator – Team Lead

AIM

From your Team Charter:• Reduce incidence of falls (fall rate) by 40% from

baseline by March 2011;• Reduce injury from falls by 40% from baseline by March

2011;• For 100% of inpatients to have a Falls Risk Assessment

on Admission by March 2011;• For 100% of inpatients who have fallen to have a Post

Falls Prevention Injury Reduction Assessment completed by March 2011

Change Ideas

List Changes you have tested during Falls VLC PDSA Cycles:

Implement Morse Falls Assessment on every client admitted to Acute Care

Identify clients who are at “high risk” for falls on the Acute Care Unit (yellow arm bands on clients, notation in Care Plan, “falling star picture outside of client’s room and over their bed, star picture on spine of chart).

Format Morse Falls Assessment to allow for multiple assessments on same page for easier trending

Institute a “Falls Prevention Injury Reduction Worksheet”

Transfer status cards on every client in their rooms

Transfer belts available in each room

Signage for washrooms on every door on Acute Care

Measures

Measure Baseline (October 2010) Final (February 2011)

% of falls causing injury 41%¹ 25%²

% of charts with completed Falls Prevention Assessment 30% 100%

% of Clients with completed falls risk assessment following a fall

0% 100%

Percentage of “at risk” clients with a documented falls prevention/injury reduction plan

20% 100%

¹ 17 falls in 3 months with 7 being Severity Level 2² 4 falls in last 3 months with 1 being Severity Level 2

Lessons LearnedList any “key” advice or insights you would like to share with other teams?

Lessons Learned/Key Insights

Any change worth while doing will take time – don’t get frustrated if one change takes weeks if not months to develop

Ensure the changes/improvements to documentation is realistic.

Ensure you put in time and energy into the development and implementation of the education component of the program.

Have someone from outside the core group to look at what you are doing and have them provide feedback – positive and negative.

Have a set time every week (month) to meet to keep on track.

Keep your Senior Management Team up to speed about your program.

Give credit where credit is due.

What are some things you will do to sustain the work on reducing falls and injury from falls and by what date?

Next Steps

Key Sustainability Steps/Plan: Target Dates

Develop educational modules for the nursing staff on Acute Care on the Falls Prevention Injury Reduction Program

April 1, 2011

Auditing the charts/unit for compliance re: identifying “high risk” clients

Will perform audits monthly (beginning April 2011) then quarterly

Provide feedback to the staff of Acute Care re: their successes and areas of improvement on program

Will provide feedback after audits are completed

Name: Sheryl L. Courtoreille, Quality Improvement Coordinator

Email: sheryl_courtoreille@gov.nt.ca

Phone Number: (867) 874 – 7168

Website: www.hrhssa.org

Contact Information