nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 1

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

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 2

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

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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?

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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

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 5

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

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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

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 7

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

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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

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 9

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

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 10

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

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 11

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!

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 12

OUR JOURNEY CONTINUES…