south west quality and patient safety improvement programme (safer care south west) west of england...
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
West of England Academic Health Science Network - launch
Preventing Harm from Patient Falls
South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Improving Safety in MentalHealth Collaborative
South of England
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Patient story
Improving Safety in MentalHealth Collaborative
South of England
“I needed to go to the toilet. I couldn’t find the call bell. I kept calling out for help. Eventually someone came but they went to get a commode and I couldn’t wait. I know I shouldn’t have tried to get out without help. I should have just gone on the sheets in the bed and then I wouldn’t have broken my hip.”
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Situation
• Within 18 months:–Reduce the total number of inpatient
falls by 10%–Reduce the number of serious falls by
20%–Reduce the number of recurrent falls by
20%
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Background
• 2 large hospital sites• Over 9000 staff• Over 1000 beds• Over 65s is the fastest growing group in population
of local area• Change in Culture amongst staff
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Strategic Falls Prevention Groupfrom Ward to Board
• Wide membership of engaged staff– Matrons, nursing, Medical, Therapy, Pharmacy,
Facilities, Audit, Patients
• Executive Sponsor• Pragmatic frontline actions to reduce falls risk on
wards• Quality Improvement methodology in developing
new tools at ward level
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
PDSA Testing Ramps
A P
S D
APS
D
A PS D
D SP A
DATA
FEEDBACK
TO
FRONTLINE
STAFF:
Complia
nce
with fo
rm
com
pletio
n
D SP A
Cycle 1A: new falls risk assessment form – 1 patient
Cycle 1B: Form modified to link directly with key interventions to prevent falls
Cycle 1D: test with 1, 3 then 5 nurses
Cycle 1C: modify form with RAG risk levels
Cycle 1E: Test form on all patients
Process Change PDSA: Testing falls prevention bundle
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Falls risk assessment
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Bed safety rail assessment
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Scheduled checking
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
After falls care
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Visual cues for staff
Involving all staff members and visitors
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Posters
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
How did we do?
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Weekly e-audit tool
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Pull from neighbouring wards
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Falls Rate per 1000 bed days from January 2011 to August 2013 Pilot Ward
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Falls rate per 1000 bed days April 2011 to August 2013 Spread Ward
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Trust-wide Falls Rate per 1000 bed days from April 2012 to August 2013
27
19
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Trust-wide Recurrent falls from April 2012 to January 2013
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
What worked
• Working with teams on the ward to test and influence the development of interventions that worked for their patients
• Regular huddles to keep up the momentum• Resisting “Spray and Pray”• Leadership at every level
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Our achievements
• Implementation of action-focused bundle across 2 large sites across 18 months with sustained improvement
• Involved all members of staff in the hospital from Switchboard to phloebotomists
• We have reduced serious harm from falls in our Trust by 30%
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Next challenges
• Focus on acute confusion assessment of patients• Improvement work on medical assessment of falls
by junior doctors• Measuring blood pressure accurately to identify
postural hypotension• New hospital!
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South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Recommendation
• Identify a pilot area with engaged staff
• Ensure you have baseline data for process measures before testing
• Get the right team together
• Set up measurement system early
• Don’t spread until you have reliable and sustained improvement