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Soteria Strains

Safe Patient Handling and Mobility Program Implementation Guide

V1.0 edited June 18, 2015

A provincial strategy for healthcare workplace musculoskeletal injury prevention.

Soteria Strains

Implementation and Program Guide

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Soteria Strains - A provincial strategy for healthcare workplace musculoskeletal injury prevention V1.0 edited June 18, 2015

Introduction

Nova Scotia’s health care sector, like publically funded health care elsewhere across Canada, is

challenged to maintain and enhance services and outcomes while at the same time constraining

the pace of increasing costs. Improving the health and safety of Nova Scotia’s health care

workers has the potential to both significantly reduce costs for health care in Nova Scotia while

enhancing patient safety and health outcomes.

The total annual cost of work-related injuries in Nova Scotia’s health care sector is estimated to

be in excess of $100 million. This figure represents both the cost of workers’ compensation and

the uninsured costs associated with work-related injuries, such as additional overtime,

recruitment and retraining, lost knowledge and experience, administrative time, and negative

patient outcomes. While these dollar figures are significant, they tend to obscure the fact that

work-related injuries cause significant pain and suffering for health care workers, forcing some

to leave their chosen profession and leaving others with significantly reduced physical

capabilities.

To improve the health and safety of health care workers in Nova Scotia, it is important to

understand the nature of the injuries these workers experience. A review of the data reveals that

in 2012, almost 80 percent of all time-loss claims reported to the Workers’ Compensation Board

of Nova Scotia (WCB) by health care workers were musculoskeletal injuries and that more than

50% of those claims were linked to some type of patient, resident, or client lift or transfer task.

This includes patient lifting, transferring, and repositioning, which we are calling patient handling

and mobility.

Purpose

The Soteria Strains Safe Patient Handling and Mobility Program guide and implementation

guide were developed by representatives from Nova Scotia’s district health authorities and their

partners. They are intended to provide acute care facilities and organizations in the province

with guidance about implementing and sustaining an evidence-based, effective safe patient

handling and mobility program within their facilities and/or organization.

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How to Use These Guides

There are two guides: an implementation guide and a program guide.

The implementation guide describes the steps involved in putting the Safe Patient Handling and

Mobility Program in place. Steps are arranged in a recommended, chronological order.

However, steps may occur concurrently or it may be appropriate for an organization to follow the

steps in a different order. Implementation is divided into seven phases outlined in the table

below.

Implementation Guide Overview

Phase Steps

1 Setting the stage for success

2 Conduct a gap analysis; identify priority units; select and train unit-based champions and managers

3 Undertake unit-based assessments; introduce safety huddles

4 Identify, plan for, and implement unit-level controls; plan for and train staff (controls, patient-risk profile, point-of-care mobility status check (PACE))

5 Audit implementation in priority units; identify areas for improvement; document and report; introduce after-action reviews

6 Identify “next”’ priority areas, and implement as per phases 2-5

7 Implement a maintenance and continuous-improvement phase: ensure ongoing monitoring and reporting, a formal review, and identification of improvement opportunities

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The program guide contains reference material that describes how to implement various

elements of the program and includes numerous tools and templates that may be used and/or

modified by the implementing organization. To improve ease of use, the program guide has

been divided into four sections, each presented as a separate document. The program guide,

its respective sections, and the chapters are outlined in the table below.

Section 1 focuses on organizational processes and activities. Sections 2 and 3 focus on

identifying and mitigating hazards – redesigning the work. Section 4 contains specific

considerations, information, and tools that may be used to supplement the processes described

in sections 2 and 3 when required.

Program Guide Overview

Section # Title Chapter # Title

1 Setting the Stage

1.1 Commitment of Leaders

1.2 Policy

1.3 Program Evaluation and Continuous Improvement

1.4 Communications, Promotion, and Engagement

2 Identifying Hazards and

Assessing Risk

2.1 Identifying Priority Areas

2.2 Unit Assessment

2.3 Patient Risk Profile

2.4 Point-of-Care Mobility Status Check (PACE)

3 Controls

3.1 Selecting Controls

3.2 Equipment Selection

3.3 Equipment Installation and Maintenance

3.4 Safety Huddles

3.5 Key Design and Installation Specifications

3.6 Training

4 Special Considerations

4.1 Emergency Situations

4.2 Bariatric Patients

4.3 Orthopedic Patients

4.4 Cognitive Impairment

4.5 Labour and Delivery

4.6 Patients with Amputations

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Program Scope

The Soteria Strains Safe Patient Handling and Mobility Program is an evidence-based, multi-

factorial program for the prevention of musculoskeletal injuries (MSIs) in acute and tertiary

health care in Nova Scotia. The program includes elements that research indicates are

necessary for an effective patient handling and mobility program. The content was also

influenced by the needs identified by multiple stakeholder groups within organizations in Nova

Scotia that provide and/or support acute and tertiary health care.

The program is one approach to safe patient handling and mobility that is consistent with

evidence-based, best-practice approaches based on the information and research current at the

time the program was developed. Other approaches to safe patient handling and mobility that

include a process to recognize and assess hazards, and control the risks associated with

patient handling and mobility tasks may be equally effective.

While many of the elements of this program may be used to support injury prevention in other

areas of health care, such as continuing care and home care, the focus of this initiative is on

acute and tertiary care. The intent is to share lessons learned and adapt this program to

address the specific patient handling and mobility needs of long-term and home care

residents/clients, workers, and workplaces. Also, MSIs related to other hazards, such as poor

workstation design and material handling, are not addressed in this program guide. Specific

programs to address MSIs related to these hazards will be needed.

Previous efforts to reduce the number of injuries associated with patient handling and mobility

often relied solely on training of staff to use proper body mechanics and manual lifting

techniques. Research has clearly shown that this type of training on its own is not effective in

reducing the frequency or severity of musculoskeletal injuries among health care workers.

Manual patient handling tasks are intrinsically unsafe because they are beyond the capabilities

of the general workforce.

Legislative Requirements

A safe and effective patient handling and mobility program is an inherent element under existing

occupational health and safety legislation. While not specifically mandated in Nova Scotia’s

Occupational Health and Safety Act or its related regulations, the Act’s “General Duty Clause”

(Section 13(1)) requires employers to take “every precaution that is reasonable” to ensure the

health and safety of all persons. More specifically, Nova Scotia’s Occupational Safety General

Regulations, Part 5, Section 26, state that employers must provide equipment and training when

“the lifting or moving of a thing or a person may be a hazard to the health or safety of a person

at the workplace.” It is clear that patient handling and mobility tasks are high risk and

hazardous; as such, employers are required to put in place programs and provide equipment

and training to staff to reduce the risk of injury.

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Acknowledgments

A special thank you is extended to the Soteria Strains Executive Leadership Group, Working

Group, Author/Editor Group, and all the partner organizations.

Thanks is also extended to all employees from all of Nova Scotia’s District Health Authorities

who took the time to complete surveys, attend feedback sessions, share their stories and

provide comments on the program and its importance.

Partner Organizations

AWARE-NS

Health Care Human Resource Sector Council of Nova Scotia

IWK Health Centre

Nova Scotia Department of Health and Wellness

Nova Scotia’s District Health Authorities

Workers’ Compensation Board of Nova Scotia Funding also provided by:

Nova Scotia Department of Labour and Advanced Education

Internal Responsibility System

The internal responsibility system is the underlying philosophy of the occupational health and safety legislation in all Canadian jurisdictions. Its foundation is that everyone in the workplace – both employees and employers – is responsible for their own safety and for the safety of co-workers. Acts and regulations do not always impose or prescribe the specific steps to take for compliance. Instead, they hold employers responsible for determining the steps needed to ensure the health and safety of all employees.

An internal responsibility system does the following:

1. Establishes responsibility-sharing systems 2. Promotes a safety culture 3. Promotes best practices 4. Helps develop self-reliance 5. Ensures compliance

See http://www.ccOH&S.ca/oshanswers/legisl/irs.html for more information.

http://www.ccohs.ca/oshanswers/legisl/irs.html

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Contents Introduction ............................................................................................................................ 2

Purpose .................................................................................................................................. 2

How to Use These Guides ......................................................................................................... 3

Implementation Guide Overview ............................................................................................. 3

Program Guide Overview ....................................................................................................... 4

Program Scope .......................................................................................................................... 5

Legislative Requirements ........................................................................................................... 5

Soteria Strains Safe Patient Handling and Mobility Program Implementation Guide .................. 9

Phase 1 – Setting the Stage......................................................................................................11

Activity 1 – Commitment of Leaders ......................................................................................12

Activity 2 – Create Policy .......................................................................................................13

Activity 3 – Fill Key Program Roles ........................................................................................13

Activity 4 – Raise Awareness & Inspire Desire for Change ....................................................14

Activity 5 – Develop Evaluation Framework ...........................................................................15

Activity 6 – Estimate and Allocate Resources ........................................................................17

Activity 7 – Communicate Progress .......................................................................................18

Phase 2 – Identify Resources and Needs .................................................................................19

Activity 1 – Conduct Gap Analysis .........................................................................................20

Activity 2 – Identify Priority Areas (Units) ...............................................................................20

Activity 3 – Select Priority Unit Peer Champions ....................................................................20

Activity 4 – Conduct Hazard Assessment Training ................................................................22


Phase 3 – Undertaking Priority Area Hazard Assessments .......................................................23

Activity 1 – Plan Priority Unit Hazard Assessments ...............................................................23

Activity 2 – Conduct Priority Unit Assessments ......................................................................24

Activity 3 – Communicate Results of Hazard Assessments ...................................................25

Activity 4 - Introduce Safety Huddles .....................................................................................25


Phase 4 – Implementing Controls in Priority Areas ...................................................................27

Activity 1 – Identify Hazard Controls for Priority Units ............................................................28

Activity 2 – Approve Hazard Controls for Priority Units ..........................................................29

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Activity 3 – Plan Implementation of Hazard Controls and Training .........................................30

Activity 4 – Implement Hazard Controls .................................................................................32

Activity 5 – Conduct Hazard Controls Training .......................................................................33


Phase 5 – Initiate Audit Phase ..................................................................................................37

Activity 1 - Audit implementation Progress .............................................................................37

Activity 2 - Identify Issues and Potential Improvements .........................................................38

Activity 3 – Introduce After Action Reviews ............................................................................38


Phase 6 – Continue Roll-Out .....................................................................................................40

Activity 1 - Identify Priority Areas (Units) ................................................................................40

Activity 2 – Identify Priority-Unit Peer Champions ..................................................................40

Activity 3 – Conduct Hazard Assessment Training ................................................................41

Activity 4 – Continue with Phases 3-5 ....................................................................................41


Phase 7 – Ensure Ongoing Improvement ..................................................................................42

Activity 1 - Monitor Program Elements ...................................................................................42

Activity 2 – Undertake Formal Program Review .....................................................................43

Activity 3 - Implement Changes Required by Review .............................................................43


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Soteria Strains Safe Patient Handling and Mobility Program Implementation Guide

Implementation Phase

Phase Name Phase Activities Notes

1 Setting the

Stage

1. Commitment of leaders

2. Prepare policy

3. Fill key program roles

4. Raise awareness and inspire desire for change

5. Develop evaluation framework

6. Estimate and allocate resources

7. Communicate progress

2 Identifying

Resources and Needs

1. Conduct gap analysis

2. Identify priority areas (units)

3. Identify priority unit peer champions

4. Conduct unit assessment training


3 Priority Unit Assessment

1. Plan unit assessments

2. Conduct priority unit hazard assessments

3. Communicate results of hazard assessments

4. Introduce safety huddles*


* Safety huddles may be introduced as a stand-alone

program element at any time.

4 Implementing

Controls in Priority Areas

1. Identify hazard controls for priority units

2. Approve hazard controls for priority units

3. Plan implementation of hazard controls and training

4. Implement hazard controls

5. Conduct hazard controls training


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5 Initiate Audit

Phase

1. Assess audit implementation progress

2. Identify issues and potential improvements

3. Introduce After Action Reviews**


**After Action Reviews may be introduced as a

stand-alone element at any time after

safety huddles have been implemented.

6 Continue

Roll-out

1. Identify next priority areas

2. Identify next unit peer champions

3. Conduct unit assessment training

4. Continue with phases 3-5


7 Ensure Ongoing

Improvement

1. Monitor program elements

2. Undertake formal program review

3. Implement changes as required based on review


Implementing a safe patient handling and mobility program is a major initiative requiring system

change, process change, and individual behaviour change at all levels of the organization. A

successful change is characterized by a solution that is effectively designed, developed, and

delivered, and that is embraced, adopted, and used by affected employees. Key factors in

successful and sustained change are:

1. Leaders commitment and support

2. Engagement and communication

3. Effective design, development, and delivery (the "technical" aspects of the change)

4. Systematic framework for ensuring the change is embraced, adopted, and used (the

"people" aspects of the change)

The activities in the implementation phases discussed in this document, in combination with the

program guide and supporting training materials, should provide everything required to satisfy

factors 2, 3 and 4. That leaves factor 1: Leadership Commitment and Support. For an effective

safe patient handling and mobility program to be implemented and sustained, leaders at all

levels, formal and informal, must be committed to the change.

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Phase 1 – Setting the Stage

This section provides guidance on the steps an organization should take in order to maximize

the success of the program in their organization. While all of these steps are important, senior

leadership commitment and participation, and communication and engagement are among the

most important.

Activities Description Lead By

1. Commitment of Leaders

Ensure senior leader commitment and participation.

● Organization’s CEO or equivalent

2. Create Policy Create, sign and communicate a safe patient handling and mobility policy.

● Senior leadership team

3. Fill Key Program Roles

Ensure the following roles are filled and responsibilities defined:

● Senior Leader Champion ● Safe Patient Handling and

Mobility Program Coordinator

● Multi-stakeholder Safe Patient Handling and Mobility Program Coordinating Committee

● Senior leadership team

4. Raise Awareness and Inspire Desire for Change

Communicate to everyone in the organization the new Safe Patient Handling and Mobility Policy and the plan to implement the program.

Messages include: ● Why the safe patient

handling program is important

● The benefits of the program ● The consequences of

maintaining the status quo ● Potential challenges

● Organization’s CEO or equivalent

● Senior Leader team ● Senior Leader Champion ● Safe Patient Handling and

Mobility Program Coordinator ● Multi-stakeholder Safe Patient

Handling and Mobility Program Coordinating Committee

Even though communicating progress is the last activity of each phase, it should be

something that is done on an ongoing basis during each activity, starting as soon as

possible and continuing as each activity is put into action. Regular, frequent checks and

monitoring will allow issues and barriers to be identified. The results of this monitoring

should be reported back to the senior leadership team, perhaps through the Senior

Leader Champion, so that successes can be acknowledged and issues can be

addressed.

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5. Develop Evaluation Framework

Begin to develop/implement an evaluation framework for the program.

● Senior Leader Champion ● Safe Patient Handling and

Mobility Program Coordinator ● Multi-stakeholder Safe Patient

Handling and Mobility Program Coordinating Committee

● Additional support as required (IT, OH&S, HR, etc.)

6. Estimate and Allocate Resources

Plan for allocation of resources to purchase/install required patient handling and mobility equipment and provide required training to staff.

● Senior Leadership Champion ● Safe Patient Handling and

Mobility Program Coordinator

7. Communicate

Progress Monitor progress and provide updates to stakeholders.

● Senior Leadership Champion ● Program Coordinator with

support of HR and/or Communications staff

Activity 1 – Commitment of Leaders

Commitment and leadership begins at the top with the chief executive officer and senior

managers. By clearly communicating and visibly demonstrating their support for the program,

this group of individuals will create a foundation upon which a successful safe patient handling

and mobility program can build. Without this, the program will almost certainly fail.

The members of the organization’s leadership team can demonstrate their commitment to and

participate in the program by ensuring:

A. They have an understanding of the safe patient handling and mobility program’s

purpose, goals and processes.

B. Measurable objectives are set, included in the program evaluation framework, and used

to guide program implementation and delivery.

C. Appropriate financial, human, and other organizational resources are put in place to

effectively plan, implement, check, review, and revise the Safe Patient Handling and

Mobility Program.

D. Implementation activities 2-4 are completed.

a. A written policy is signed (see “Section 1.2 Policy”) outlining the organization’s

commitment to the Safe Patient Handling and Mobility Program.

b. Roles are defined, responsibilities assigned, accountabilities established, and

authority delegated as needed to implement the program.

c. Raise awareness and inspire desire for change

Refer to Program Guide "Section 1.1 – Leadership Commitment" for more details.

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Activity 2 – Create Policy

A safe patient handling and mobility policy sets a structure to ensure that patient lifts, transfers

and repositioning are performed in a way that minimizes risk of injury to health care workers and

patients. It is an important element in a program with multiple elements and guides

organizational-level decisions and actions as well as frontline health care worker decisions and

actions. While a policy is necessary, it is not sufficient, by itself, to mitigate the risk to health

care workers and patients during patient handling and mobility activities.

A safe patient handling and mobility policy should:

1) State the organization’s commitment to the safe patient handling and mobility program.

2) State the intent of the policy; to protect the health of staff and patients.

3) State that all manual patient handling and mobility tasks are to be avoided wherever

possible.

4) Clarify the roles and responsibilities of health care workers, support workers, and

administrators to help maintain sustainability of the program.

5) Be understood by all health care workers and reviewed on a regular basis.

A policy provides a clear vision of why the program is being implemented, along with its goals

and objectives, and provides a means to hold people accountable for their participation.

Once the policy is finalized and signed off by the organization’s CEO, The senior leadership

team should demonstrate its support for the policy by taking part in a communication process to

inform all staff, at all levels, about the policy, why it is needed, the expected benefits, and the

plan for implementing the program. It is important to include patients and their families when

communicating about the policy so that they understand how the safe patient handling and

mobility program will benefit them and their health care providers.

Refer to section 1.2 – Policy, Appendix 1.2.1 for more details and a sample policy statement

Activity 3 – Fill Key Program Roles

It is essential to define the roles and responsibilities for the safe patient handling and mobility

program and clearly communicate these to the individuals who will be assuming those roles.

The safe patient handling and mobility policy may include one or more statements regarding the

roles and responsibilities various people, positions, or departments have under the program.

However, a more detailed listing of the specific roles and responsibilities for specific individuals

and positions should be developed and approved by the organization’s senior leadership team.

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At this stage in the implementation of the program, it is important to clearly define the roles and

responsibilities for the:

1) Senior Leadership Champion

2) Safe Patient Handling and Mobility Program Coordinator

3) Multi-Stakeholder Safe Patient Handling and Mobility Program Coordinating Committee

a. Safe patient handling and mobility program coordinating committee

recommended membership:

i. Senior Leadership Champion

ii. Safe Patient Handling and Mobility Program Coordinator

iii. VP of Clinical Services (or equivalent) - if not already the Senior

Leadership Champion

iv. Front line health care workers with multiple professional representation as

required (RN, PT, OT, DI, etc)

v. OHS

vi. Union

vii. Senior Executive Facilities Management/Engineering

services/Maintenance/Operations

viii. Biomedical Engineering

ix. Procurement Officer

x. Finance

xi. Infection Prevention and Control

xii. Patient quality and safety

Roles and responsibilities for these individuals/groups should be specific, well documented, and

clearly communicated to the individual(s) involved and the organization as a whole. Some

possible roles and responsibilities for these individuals/groups are described in section 1.2

Policy, Appendix 1.2.2 - Roles and Responsibilities.

Activity 4 – Raise Awareness & Inspire Desire for Change

Implementing an effective safe patient handling and mobility program is a major change process

for any health care organization, and as such, it requires well-planned, effective communication.

Raising awareness demonstrates commitment to the program and helps ensure its success.

And while good communication will not guarantee the success of a safe patient handling and

mobility program, it is well known that a lack of effective communication can derail a program

before it even starts.

It is helpful to develop, approve and implement a communications plan to ensure that everyone

who should be aware is made aware of the new policy, once created and signed, and also that

key messages related to the program are communicated and understood. Suggested audiences

and messages are referenced in the program guide section 1.4 - Communication, Promotion

and Engagement, Appendix 1.4.1 – Suggested Key Messages by Audience and Phase.

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Communication plays an essential role in meeting numerous goals. Communications should be

two-way and will require multiple stakeholders to be involved. When these goals are achieved

the normal and expected reluctance for change will be transformed. The goals are:

Raise Awareness – Achieving this goal requires answering why this program is

important to the organization and how it will benefit the organization. Note: Much of

this work began with the engagement process used to create this implementation

guide and its companion program guide. Organizations can capitalize on this

groundwork when creating the communications plan by referring back to results from

the perception survey and face-to-face engagement sessions. Find these reports

and more at www.soteriahealth.ca.

Inspire Desire – Achieving this goal requires focusing on the benefits of the program

and the consequences of not initiating change. There will be different messages for

different groups and individuals, who will be impacted in different ways by the

program. While communicating personal benefits is important, this is also a good

time to identify potential challenges, barriers, and the apprehension that workers

might have. The method of communication is important to consider when inspiring

the desire to change. While email and electronic communications may seem more

efficient, they are not as effective as face-to-face conversations. Ideally, these

conversations occur one to one, but may also be done in team meetings. It is to be

expected that even when individuals are inspired and looking forward to change they

may still have some reluctance to accept a new way of doing things.

Grow Knowledge – To achieve this goal, people need to understand what they

need to know about the program. Communications should be focused on answering

questions such as: What is changing? What isn’t changing? How is the new

program the same as how we currently practice? What’s in it for me? How will

patients benefit? Another key message is to ensure awareness of what training will

occur prior to or during the change. People must be sure that they will have the skills

required for the program. Answering questions such as how, when, and why training

will occur will assure people they will be prepared for the change in the way they

practice as the program is implemented.

Refer to Program Guide, “Section 1.4 – Communications, Promotion, and Engagement” to

create and execute a communication, promotion, and engagement plan.

Activity 5 – Develop Evaluation Framework

When implementing a safe patient handling and mobility program, it is important to clearly

define and communicate the goals and objectives of the program. Once this is done, the

organization needs to consider how the program will be monitored and evaluated. A well-

designed evaluation framework will allow the organization to determine if the resources and

effort put into the program were justified and if the program has met its goals and objectives. It

http://www.soteriahealth.ca/

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will also help to ensure that the safe patient handling and mobility program can continue to

improve over time.

The Multi-stakeholder Safe Patient Handling and Mobility Program Coordinating Committee

(refer to Activity 3) should be tasked with identifying high level goals and objectives for the

program. The Committee should be provided with support and resources to assist with this

work, including:

Training on the Soteria Strains evaluation framework (refer to program guide section 3.6

- Training)

Adequate, dedicated time and reasonable due dates to complete the work

Information on the types of data currently collected, how that data is collected and how

it is used

Access to program guide section 1.3 Evaluation and Continuous Improvement

The Safe Patient Handling and Mobility Program Coordinator should review the indicators in

Soteria Strains Program Guide Section 1.3, Appendix 1.3.2-4, in order to identify if the

organization is currently collecting data related to each indicator and, if so, how. Examples of

how an organization may be collecting data for the indicators required to evaluate the safe

patient handling and mobility program include:

Reports from existing reporting systems, including adverse-incident records,

injury/incident reports

Number of health care providers attending safe patient handling and mobility training

Proportion of total health care providers attending safe patient handling and mobility

training

Hazards and other items discussed at health and safety meetings (meeting minutes)

First aid and incident records for the unit or organization

WCB claims data

Absenteeism records

Health care provider turnover rates

Employee complaints (e.g., workload, equipment and software problems, pain and

discomfort)

Workplace assessments and hazard checklists

Audits to observe working practices and activities

Surveys related to safe patient handling and mobility via self-report questionnaires

Time off for medical visits as a result of patient handling and mobility work strain

Interviews with health care providers involved in patient handling and mobility

Worker morale and satisfaction measures (e.g., suggestion boxes, group meetings,

surveys)

If the organization isn’t currently collecting data related to an indicator, they should investigate

how this data could be collected, for example creating a survey for specific populations. Refer to

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Section 1.3, Appendix 1.3.6, for resources related to developing surveys related to the

implementation of the safe patient handling and mobility program.

The Coordinator should compile the results of this review and develop a plan for evaluating the

program. The plan should specify how data needed for each indicator is or will be collected, and

who will be responsible for collecting this data. This plan should be provided to the Program

Coordinating committee for their review and feedback. Approval for the plan should be obtained

from the appropriate level of management (e.g. senior leader sponsor).

It is important that any systems or processes needed to collect the data for required indicators

be either in place or set up as soon as possible so that the information gathered can be used for

both evaluation and program-improvement purposes. In addition, the Multi-stakeholder Safe

Patient Handling and Mobility Program Coordinating Committee will generate program

evaluation resource materials to support the efforts of individuals/groups, such as managers

and peer champions.

Activity 6 – Estimate and Allocate Resources

Implementing an effective safe patient handling and mobility program requires an investment in

both equipment and people. It is not sufficient simply to tell health care providers to work safely

or use good body mechanics when most patient handling and mobility tasks are high-risk tasks

when performed manually. It is important to plan for and allocate the resources to buy and

install the required equipment and to train staff in methods and techniques that will let them

safely handle and move patients.

Resource issues that need to be considered include:

Initial equipment purchase costs (including required accessories)

Equipment installation costs (including any required retrofitting of spaces – electrical,

structural, etc.)

Ongoing equipment maintenance, testing, and inspection costs

Ongoing costs to replace accessories

Space where health care providers can and be trained to use equipment and can test

equipment

Time and, as required, replacement staff so that health care providers can be trained in

safe patient handling and mobility assessments and methods

Time and, as required, replacement staff to conduct the training sessions

Opportunities for managers and other support staff to receive required training

Funding and communications resources to ensure that all stakeholders are kept

informed about the implementation and ongoing success of the safe patient handling

and mobility program

The Safe Patient Handling and Mobility Program Coordinating Committee selected in Activity 3

will select a number of units to launch the program in. The size and number of units should be

realistic. Refer to Phase 2.2: Identify Priority Units and Section 2.1 of the program guide for

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more details on selecting units to begin implementation. For planning purposes, it may be

helpful to use the gross-budget-estimation process as shown. This is based on previous

experience in jurisdictions within Nova Scotia and PEI.

This estimate includes cost of equipment and training, but not maintenance of equipment. Also,

there is an assumption that no major structural issues are present within the facility that requires

significant renovation and/or upgrading.

Activity 7 – Communicate Progress

The Senior Leader Champion and, once identified, the Program Coordinator should review the

steps outlined in Activities 1-6 to determine which steps have been completed, those that are in

process, and any that have been missed or were considered complete, but not implemented

fully. They might:

Compare the specific outputs (e.g., the Safe patient Handling and Mobility Policy) to

examples provided in the Soteria Strains Safe Patient Handling and Mobility Program.

Ensure they understand their own responsibilities under the program and that these

have been communicated to others in the organization.

Make certain that the Safe Patient Handling and Mobility Program Coordinating

Committee have been established and understand its purpose and responsibilities.

Ensure staff in various areas of the organization are aware and understand the reasons

why the policy was created and what they can expect as the program is implemented.

Confirm the evaluation framework is created and approved; systems and procedures to

collect required data are identified, planned for, and created; and that individuals

responsible for collecting the data are doing this.

Ensure that the organization has a plan for allocating financial and personnel resources

so the program can be implemented in a timely and efficient manner, and so that it can

meet its goals and objectives.

After the review is completed the Senior Leader Champion and/or Program Coordinator should

inform all stakeholders of results and next steps.

Estimated cost/unit = (# beds) x ($3000 ±15%)

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Phase 2 – Identify Resources and Needs

The goals of phase 2 are to identify which units within an organization are a priority for

implementing the safe patient handling and mobility program, and select and train unit-based

peer champions. Once the champions are trained, they will work with the managers from priority

units to introduce and hold safety huddles.

Activities Brief Description Completed By

1. Conduct Gap Analysis Conduct facility/organization-

level gap analysis

Program Coordinator with assistance from

○ OH&S and/or ○ HR

2. Identify Priority Areas (Units)

Identify priority units for initial implementation

Program Coordinator with assistance from:


and input from the: ○ Safe Patient Handling and Mobility Program Coordinating Committee

3. Select Priority Area (Unit) Peer Champions

Select unit-based peer champions for priority units

(suggested two minimum per unit depending on size and

nature of unit)

Program Coordinator with managers from priority units

4. Conduct Hazard Assessment Training

Train unit-based peer champions and managers for

priority units (unit assessment module)

Program Coordinator with support of OH&S and/or additional staff

5. Communicate Progress Monitor progress and provide

updates to stakeholders Program Coordinator with support from HR and/or Communications staff

Even though communicating progress is the last activity of each phase, it should be

something that is done on an ongoing basis during each activity, starting as soon as

possible and continuing as each activity is put into action. Regular, frequent checks and

monitoring will allow issues and barriers to be identified. The results of this monitoring

should be reported back to the senior leadership team, perhaps through the Senior Leader

Champion, so that successes can be acknowledged and issues can be addressed.

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Activity 1 – Conduct Gap Analysis

Conducting a facility or organizational-level gap analysis is one of the first and most important

steps required to implement a safe patient handling and mobility program. It is very likely that

acute care facilities will have already put into place various controls to reduce the risk of injuries

associated with patient handling and mobility tasks. It may be that health care workers have

been trained on effective patient handling techniques or one or more pieces of equipment have

been purchased and installed. It is possible that lift teams were created but are no longer

together. The organization may even have a safe patient handling and mobility program in

place. Understanding what an organization has and is doing to help prevent injuries related to

patient handling and mobility is vital before moving forward. The gap analysis will help you to

see what is in place, what is working, what isn’t working, and if additional program elements

need to be instituted to help make the program effective. It will help reinforce and invigorate

what is already in place, which can reduce the amount of effort and time required to implement

an evidence-based safe patient handling and mobility program.

Activity 2 – Identify Priority Areas (Units)

When considering how to implement a safe patient handling and mobility program, consider

whether it is possible and reasonable to try to implement it in all areas of the organization at

once. As a first step, create a list of the areas where patient handling and mobility tasks are

performed and then prioritize them for action based on a review of key indicators and

information.

Typically this work will be done by the Multi-stakeholder Safe Patient Handling and Mobility

Program Coordinating Committee, once identified.

Section 2.1 of the program guide provides a step-by-step process that is supported by training

material and may be used to enhance your organization’s current process.

Activity 3 – Select Priority Unit Peer Champions

Once the priority units have been identified, the Program Coordinator should work with the

Managers from these units to select unit based Peer Champions. Each unit should have at least

two peer champions, and larger units should have more to ensure adequate coverage. Each

unit based peer champion will be a resource for safe patient handling and mobility. With the

support of their manager, they will help train others on their unit, reinforce and model safe

handling behaviours, answer questions from co-workers, help co-workers to problem solve

difficult patient handling situations, etc.

A template for completing the gap analysis will be creating during early pilot phases to be

included in section 1 of the Soteria Strains Safe Patient Handling and Mobility Program Guide.

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Follow these steps to select unit based peer champions:

1) The Program Coordinator and manager should meet with all care staff on the priority

unit(s). Ideally this should be a group meeting with all staff present, but individual or

small group meetings will also suffice. The coordinator and manager should:

a. Review the safe patient handling and mobility policy with the staff.

b. Inform the team they have been selected as a priority unit and why.

c. Tell the team about the role of the unit based champion. The manager and

program coordinator will provide material that describes the role and

responsibilities.

d. Provide an opportunity, during this meeting, for the Senior Leader Champion to

communicate the executive leader team’s support and expectations for the

program.

2) To generate a list of candidates the Program coordinator should ask for:

a. The manager to identify a list of candidates.

b. Health care workers to nominate individuals.

c. Request health care workers volunteer.

d. Individuals who are listed who meet the requirements to fill the role of unit peer

champions should be considered.

3) The Program Coordinator and manager should then meet with the selected candidate

champions from each unit, either separately or in a group, to review the responsibilities

of the unit peer champion and the training plan and confirm participation.

4) Peer champion selections should be shared with all unit staff.

The Role/responsibilities of the Unit Based Peer Champion are to:

Provide training to peers on their unit.

Model safe patient handling and mobility behavior.

Act as an ongoing resource for peers, answer questions, and help them problem solve

difficult patient handling and mobility situations.

Participate in continuous improvement efforts that promote, improve, and sustain the

program as well as evaluate training effectiveness.

Act as a resource for unit based peer champions from other units.

Refer to Soteria Strains Safe Patient Handling and Mobility Program Guide Section 1.2 Policy for

more details on program roles and responsibilities.

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Activity 4 – Conduct Hazard Assessment Training

All the peer champions and managers from the priority units will need to be trained so that they

can properly fulfill their responsibilities. A plan needs to be put in place to enable training to be

delivered in a timely manner.

For this phase, each peer champion will require training on:

Unit assessment and control selection

How to conduct safety huddles

Helping with continuous improvement efforts that promote, evaluate, and sustain the

program. Resource material will be provided by the Multi-stakeholder Safe Patient

Handling and Mobility Program Coordinating Committee (generated in Phase 1, Activity

5).

For this phase, each manager will require training on:

Hazard identification, risk assessment, and control selection

Safety huddles

Continuous improvement efforts that promote, evaluate, and sustain the program.

Resource material will be provided by the Multi-stakeholder Safe Patient Handling and

Mobility Program Coordinating Committee (generated in Phase 1, Activity 5).


The Senior Leader Champion and, the Program Coordinator should review the steps outlined in

Activities 1-4 to determine which steps have been completed, those that are in process, and any

that have been missed or were considered complete, but not implemented fully. They might:

Review the process used to collect data for identifying priority units to identify gaps and areas for improvement.

Talk to the managers and staff from across the organization to learn how they feel about the selection process and communication with staff.

Connect with the managers and staff on the priority units to discover how they feel about the selection process and to make sure they understand the role and purpose of peer champions.

Meet with the peer champions to understand how they feel about the selection process and the effectiveness of their training.

Collect training evaluations from the peer champions, review and analyze these to identify possible improvements to content and delivery of the training.



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Phase 3 – Undertaking Priority Area Hazard Assessments

During Phase 3 the Program Coordinator will work with managers and, ideally, unit based peer

champions from the top priority units to plan and schedule the completion of unit based risk

assessments. Also, the peer champions will work with their managers to introduce safety

huddles to the health care providers on the unit.


1. Plan Priority Unit Hazard Assessments

Plan and schedule unit based risk assessments for priority units

Program Coordinator with managers and unit-based champions from priority units

2. Conduct Priority Unit Hazard Assessments

Conduct unit based hazard identification and risk assessments

for priority units

Managers

Unit based champions with support of selected unit staff,

Program Coordinator

and/or OH&S staff

3. Communicate Results of Hazard Assessments

Create prioritized list of hazards to be controlled based on results of unit

based assessments.

Communicate results

Managers

Unit based champions with assistance from selected unit staff, Program Coordinator, and/or OH&S staff

4. Introduce Safety Huddles

Plan and deliver training for safety huddles (Safety Huddle training will

be available as an e-learning module and may be introduced as a stand- alone element at any time during

implementation)

Document work procedures as required.

Unit based champions and managers for priority units

5. Communicate Progress

Monitor progress and provide

updates to stakeholders

Program Coordinator with support from HR and/or Communications staff

Activity 1 – Plan Priority Unit Hazard Assessments

The Program Coordinator should meet with the managers and peer champions to review the

process for conducting the unit assessments. Even though the peer champions and managers

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should have already been trained on hazard identification and risk assessment, they may need

guidance and assistance to conduct the assessment.

The unit assessments should be conducted as soon as possible, taking into account the needs

of patients on the unit and work schedules. Depending on the size of the unit, the risk

assessment may take anywhere from 3-4 hours, plus time to collect relevant data and review

the results.

Refer to “Section 2.2 – Unit Assessments” in the program guide for more information on

identifying hazards and assessing risk associated with patient handling tasks.

Activity 2 – Conduct Priority Unit Assessments

The unit assessments have three basic components:

1) Gather and review unit specific data

2) Identify patient handling hazards (high risk tasks) on the specific unit

3) Assess the risk for each of the identified hazards

This will allow the manager, unit champion, and participating health care workers to create a

prioritized list of hazards and potential controls for those hazards. It is important at this stage to

understand two things. First, there may be multiple hazards that all have the highest level of risk

associated with them, and it may not be possible to implement controls for all of these hazards.

Second, there may be high risk hazards that need to be controlled, but doing so may take a

great deal of time or be prohibitively costly. In some cases, there may be no known way to

control the hazard. So even though these hazards do need to be addressed, they may require

further study or need to be put into a long-term planning cycle. As a result, lower risk hazards

may become a higher priority at the unit level.

Hazards rated as low-to-medium risk can often be controlled simply and immediately. These

may be dealt with before others are considered or while planning to implement more

complicated controls.

Finally, when prioritizing hazards for controls, it is vital to take into account the issues and

concerns raised by health care workers on the unit. These issues may not always present the

highest risk of injury to staff or patients, however, if no action is taken worker’s level of

engagement may be negatively impacted. This could interfere with future efforts to control

exposure to high risk hazards.

Refer to “Section 2.2 – Unit Assessments” for detailed steps on completing the assessments as

well as a template for documenting results.

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Activity 3 – Communicate Results of Hazard Assessments

Once the Unit Assessment is complete and a list of hazards created and prioritized for control, it

is important to share this information with all of the health care workers on the unit. A variety of

methods should be used to communicate this information and explain why specific hazards

were selected as priorities. This information should be shared during a meeting of all unit staff,

but, alternatively, it could be shared in small group meetings or one-on-one discussions.

Managers and peer champions should resist the urge to communicate this information via email

or by posting a notice on a bulletin board. Emails and notices can be used in conjunction with

meetings, but should not be used as a primary means of communicating this information.

Communications can be developed based on processes and documents generated from

templates in “Section 2.2 –Unit Assessments”. Also, the wrap-up meeting that occurs after the

site visit (see section 2.2) provides an excellent opportunity to communicate early findings to the

participating health care workers.

Activity 4 - Introduce Safety Huddles

Safety huddles help create a culture of performance excellence and continuous learning and

improvement. Often safety issues related to patient handling and mobility are not captured in

incident reports. Without knowing what the issues are, it is impossible to take corrective action.

Safety huddles provide managers and staff a means to share information about the current state

of the unit, discuss safety related concerns, and highlight any new or ongoing issues and how

they can be addressed.

Safety huddles offer health care providers an opportunity to discuss and address safety

concerns they have seen on their units/departments to prevent incidents or near misses in the

future. These huddles with the inter-professional team are held at the same time each day and

typically take as little as 15 minutes to complete. Safety issues raised may include:

New bariatric patients

Significant patient status changes that may result in:

o the need to change how they are handled/moved

o increased risk of falls, etc.

equipment/device issues

environmental concerns

staffing complements

Safety Huddle training will be available as an e-learning module and may be introduced as a

stand-alone element at any time during implementation. After a unit assessment is complete,

safety huddles should be regularly conducted in the unit and any issues not previously identified

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should be documented. This information may be used to adjust the list of priority hazards or

they may help guide the selection of controls for these hazards.

Guidance on how to run effective safety huddles and how to document issues arising from them

can be found in section 3.4 of the program guide as well as the e-learning module.





Review the planning process used for the unit assessments to identify if anything was

missed or could be improved. This should be done in conjunction with the unit manager

and peer champions.

Review the assessment process with the unit manager and peer champions to see if

anything was missed or could be improved.

Talk with staff on the unit to find out what they feel about how the assessment was

conducted, whether they understand why and how the assessment was conducted,

whether there was adequate opportunity for staff to express their opinions, if the results

of the assessment were effectively communicated to the staff, and if they were satisfied

with the results.

Meet with the manager and peer champions to learn what they know about safety

huddles and how they are being used on the unit. If there are concerns, discuss how

safety huddles can be improved



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Phase 4 – Implementing Controls in Priority Areas

In Phase 4 the Program Coordinator will work with the unit peer champions, managers, and

selected staff to identify the controls needed to reduce the risk associated with each hazard.

These controls should then be approved, or alternative controls selected, and implemented.

When implementing controls, it is important to recognize that control related policies and/or

procedures will need to be created, and staff will need training related to the control (to

understand new policy/procedures, to follow new work method/reporting procedures, to use new

techniques and/or pieces of equipment, etc.) As such, it is essential to create an

implementation plan that helps ensure controls are effective and employees are ready and able

to use them. This plan should be communicated to required stakeholders.


1. Identify Hazard Controls for Priority Units

Identify hazard controls based on the results of the unit assessments

Managers

Unit champions

Select staff from each unit,

Support from:

Program Coordinator and/or

OH&S and HR as required

2. Approve Hazard Controls for Priority Units

Review and approve controls for implementation

Communicate results

Manager/senior leader with required budgetary/fiscal accountability; with input from the Program Coordinator, the Safe Patient Handling and Mobility Program Coordinating Committee and others (e.g., purchasing, facilities, HR)

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3. Plan Implementation of Hazard Controls and Training

Plan for implementation of controls including, if necessary, testing and

trialing

Plan for training – Unit based champions (Safe patient handling

Trainer Module)

Plan for training – Managers and Health care Workers (Safe patient handling

Module)

Managers

Unit-based champions

Support from:

selected health care workers from units

Program Coordinator

4. Implement Hazard Controls

Implement identified controls

Monitor implementation process

Create and approve all required control-related policies and procedures

Train unit-based champions to provide

hazard control training

Facilities

Purchasing

Suppliers

Managers

Unit-based champions

Support from:

Program Coordinator

OH&S, and/or HR

5. Conduct Hazard Controls Training

Train health care workers in units where

controls are being implemented

Program Coordinator and/or

Unit-based champions and/or

Equipment suppliers and/or

OH&S staff and/or

HR staff

6. Communicate

Progress

Monitor progress and provide updates

to stakeholders

Program Coordinator

Support from:

OH&S staff and/or

HR and/or

Communications staff

Activity 1 – Identify Hazard Controls for Priority Units

The Program Coordinator should work with the unit manager and peer champions to identify

possible controls for each of the prioritized hazards identified. Ideally, one or more additional

staff members from the unit should assist with this process.

The peer champions should review the basic concepts of hazard control and risk mitigation with

all participants before looking for effective controls. The team working to identify controls should,

at a minimum, understand the hierarchy of controls. Controls can be grouped into four

categories:

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Elimination

Substitution

Engineering

Administrative

Personal Protective Equipment (PPE)

Controls should only be selected from a category if options in a higher category are not

possible. Therefore, when selecting controls, eliminating the hazard should be considered first.

If elimination and substitution is not possible engineering controls (such as equipment or task

redesign) should be considered next. Administrative and PPE controls should only be

considered if engineering solutions are not possible. Note that all engineering controls require

training (an administrative control).

Categories of the hierarchy of controls are described further in “Soteria Strains Safe Patient

Handling and Mobility Program Guide, Section 3.1 - Selecting Controls”.

Refer to “Soteria Strains Safe Patient Handling and Mobility Program Guide, Section 3 -

Planning and Implementing Controls” for more details on identifying, selecting and prioritizing

controls for hazards.

Activity 2 – Approve Hazard Controls for Priority Units

The Program Coordinator should review the list of recommended hazard controls and provide

the Safe Patient Handling and Mobility Program Coordinating Committee and any other

appropriate departmental representatives (OH&S, HR, facilities, etc.) with an opportunity to

comment.

Based on the results of the review process, the Program Coordinator should, if necessary,

modify the list of recommended controls. This list and the specific reasons for changes should

then be discussed with the unit manager and peer champions.

The final list of recommended controls should be presented to the Senior Leader Champion and

then to the facility/organization’s senior leader team for approval.

All health care workers on the unit should be informed of the approved controls. Ideally this

should be done by having the manager and/or peer champions meet with all staff to review the

list of approved controls. They should be prepared to answer questions about why specific

controls were selected and the next steps in the process for implementing controls.

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Activity 3 – Plan Implementation of Hazard Controls and Training

During this activity, the Program Coordinator develops a plan for implementing the approved

controls, working with the unit manager, peer champions and others such as OH&S and/or HR

staff, quality, risk and patient safety, facility engineering and procurement. The plan should be

developed, documented and shared with the unit and support team. The plan will change over

time and changes should be tracked and updated. The most recent version of the plan should

always be available to the team. The plan should include:

A complete list of requirements; this will be largely complete from previous steps and

should be refined at this stage.

Constraints such as budget limits, timelines and scheduling issues that cannot be easily

altered.

A breakdown of activities/steps to complete, described in a logical order (i.e. procure

equipment, install equipment, inspect equipment, train staff).

When refining the requirements list for each control, consider whether more research or

investigation is required. Some examples include:

When equipment is recommended, is it clear exactly what piece of equipment is

needed?

If a work area needs to be modified, is it clear which work area(s) are involved and what

the specific modifications are?

If additional staff training is recommended, is it clear exactly what the goals of the

training are?

Other questions to consider when refining the requirements list are:

Does the control require significant redesign or layout modifications of the unit or

associated work areas?

Will a new policy be required to support the implementation and/or use of the control?

Will a new work procedure be required to support the implementation and/or use of the

control?

Will staff training be required so that the control can be used effectively?

Will required equipment have to be tendered and/or trialed before purchase?

Will the installation or implementation of the control interfere with the delivery of care on

the unit?

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Possible points to consider when listing constraints include:

budget

patient care issues

bed utilization/patient flow

facility age/design/size

timelines

Infection Prevention and Control

number of and schedules of healthcare workers on unit

other projects or initiatives

Some points to consider when defining and sequencing activities:

For equipment, it is important to know exactly what type, make and/or model of

equipment is needed. Refer to Soteria Strains Safe Patient Handling and Mobility

Program Guide Section 3.2 - Equipment Selection for a process to test or trial various

types of equipment.

Frontline health care workers need to be actively involved and engaged when:

o testing or trialing equipment

o modifications to the work space or workstation are identified

o when developing new policies, procedures, and work methods

Include time and resources for effective and meaningful staff consultation and

engagement. Staff engagement, while time consuming, can help avoid problems and

frustrations because workers, as the experts on how their jobs are done, are able to

identify concerns and possible solutions early in the selection, design, or writing phase.

Facility/Engineering should be involved when significant design changes are required.

Also, refer to Soteria Strains Safe Patient Handling and Mobility Program Guide Section

3.5 - Facility Design.

Consider the possible presence of asbestos-containing materials and/or inadequate

structural elements when installing any equipment.

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It is important to communicate the plan and all changes to frontline health care workers, senior

leadership, and others in the organization. Refer to Soteria Strains Safe Patient Handling and

Mobility Program Guide Section 1.4 - Communications, Promotion, and Engagement for

information about creating a communication plan.

Activity 4 – Implement Hazard Controls

Once a plan for implementing approved control(s) is completed, the next step is to put the plan

into action. The Program Coordinator should monitor the implementation plan to ensure it is

being followed, identify and work to resolve any barriers, and keep the unit managers and peer

champions informed about progress. If barriers do arise, the Program Coordinator should meet

with appropriate staff to resolve and overcome them. If changes to the implementation plan are

required, the Program Coordinator should get approval for these changes and ensure that

everyone is informed about them.

The Program Coordinator should make sure all necessary departments are consulted with and

that the planned staff involvement and engagement takes place. If installing equipment the

Program Coordinator should also verify that the make, model, and type of equipment is correct

before it is installed, and ensure it is being installed where and when it should be. It is also

important that the Program Coordinator work with health care workers from the unit and OH&S

to make certain any new hazards created during implementation or installation are identified and

controlled.

Create and Approve Required Policies and Procedures

When the implementation plan for approved controls is finalized, it will specify what, if any, new

policies and/or procedures will need to be created and approved. As this can be a time

consuming process, work should begin on these as soon as possible. Most organizations will

already have a process for the creation and approval of new policies and procedures and, if so,

this process should be followed. Some additional things to consider:

Who should be on the team that creates the policy and/or procedure? The team should

include members of the Multi-stakeholder Safe Patient Handling and Mobility Steering

Committee plus any other people (as needed) from other areas not already represented.

Will feedback be obtained on the policy or procedure? If so, how, when, and from

whom?

How will the new policy and procedure be communicated? How and when will staff be

trained on the details, requirements, responsibilities, expectations, and accountabilities

related to the new policy and/or procedure?

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Train Unit Peer Champions to Provide Hazard Control Training

Unit peer champions will provide training on safe patient handling and mobility to colleagues on

their units. As controls are being implemented, the champions should complete their training.

In this phase, unit peer champions require training on:

Safe patient handling and mobility principles and selection criteria for assessment

methods including patient risk profiles and the point-of-care mobility status check

(PACE).

After Action Reviews.

How to facilitate training sessions for their peers.

Activity 5 – Conduct Hazard Controls Training

Perform Assessments – Patient Risk Profile

An important element of an effective safe patient handling program is the use of patient risk

profiles, which are used as a baseline for identifying how to safely lift, transfer, and reposition a

patient. These profiles capture key information about the patient at various times during the

patient’s stay on a unit or facility.

See section 2.3 - Patient Risk Profile of the Soteria Strains Safe Patient Handling and Mobility

Program Guide for details on how to complete the patient risk profile.

Points to consider:

Documentation of the patient risk profiles should move with patients as they move

between different units in the facility or are transferred to another facility. Patient risk

profiles should be updated as the patients’ status changes.

Refer to Section 2.3 - Patient Risk Profile of the Soteria Strains Safe Patient Handling

and Mobility Program Guide for details of the assessment.

The patient risk profile can help determine the specific types of lifts, transfers, or

repositioning techniques required. It will also indicate if specialized equipment is required

(e.g., bariatric lift and sling, non-standard beds). Without this information, care staff may

be at an increased risk of injury because the equipment and special instructions needed

for safe lifts or transfers is not available when needed.

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Complete Point-of-Care Mobility Status Check (PACE)

The Point-of-Care Mobility Status Check (PACE) is another vital element of a successful safe

patient handling program; it is related to the patient risk profile, but is used by all health care

workers that need to lift, transfer and/or reposition, a patient.

The PACE Mobility Status Check comprises is divided into four sections that health care

workers need to consider prior to making the decision to engage in any patient handling and

mobility activity. These are:

Physical: the patient’s current physical status (strength, balance, etc.).

Agitation/Aggression: is the patient agitated or displaying aggressive behavior, or does the patient have a history of aggressive behavior.

Communication: is the patient able to respond to simple questions and follow instructions.

Environment: is the environment (work space/area, floor, access, obstructions, etc.) safe for patient handling whether the patient is able to fully assist with the transfer or if equipment is used to perform the handling task

Health care workers will be trained on how to use this tool, which takes staff through a series of

questions that determine if a condition is “Green,” “Yellow,” or “Red”. If any “Red” conditions are

found, then the care provider needs to determine a safe way to lift, transfer, or reposition the

patient.

The PACE should be conducted by all care staff every time they are required to lift, transfer, or

reposition a patient. Results of the PACE will inform health care workers choices regarding the

approach to a patient handling or mobility task. A more conservative approach and/or further

assessment may be required based on changes to the patient’s physical or cognitive status. Or,

the patient’s environment might have changed (e.g., a new piece of medical equipment or

furniture has been brought into the patient’s room) that may create increased risk to the health

care worker or patient.

As noted, if the outcome of the PACE Assessment conflicts with the patient’s current safe lift,

transfer, and repositioning plan, then the health care provider should err on the side of caution,

use the safest method to perform the lift or transfer, and collaborate with their co-workers, unit

peer champions, and manager to revise the lift and transfer plan. The manager should, if

required, arrange for another mobility assessment to be completed.

See Point-of-Care Mobility Status Check (PACE) in the Soteria Strains Safe Patient Handling

and Mobility Program Guide for more information.

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Train Workers on New Controls

Health care workers will need to be trained on any newly implemented control. They might need

to be trained on how to safely and effectively use a new piece of patient handling equipment. It

could be that they also need to be trained on new work methods, assessment protocols, or

reporting procedures. And, of course, they will need to be informed and trained on any new

policies or procedures created.

For equipment related controls, it is often possible to begin training unit staff on how to use

specific pieces of equipment before this equipment is actually installed on the unit. For instance,

if the equipment exists in other units, then these units could be used to train staff prior to the

equipment being installed on their own unit. Or, if space exists, it may be possible to have

equipment installed in a testing /training room so that staff can be trained and provided with

refresher training as needed. Finally, if the organization has multiple facilities some of which are

already using the specific equipment, then it might be possible to provide training to staff in one

or more of these facilities.

No matter the circumstances, because there will always be a training element associated with

new controls, it is vital to plan for how training will be delivered in a timely and efficient manner.

For each element of training required, these questions need to be answered:

What are the goals, objectives, and content of the training?

Who needs to be trained? Only health care workers, Managers, Directors, VPs and

senior leadership? Any others?

When will the training take place and how long will the training session last? How will

affected units cover for employees who are participating in the training?

Where will the training take place? Will all required resources to support the training

(equipment, accessories, mock patients, seating, LCD projector, etc.) be available and is

in the training area/room? Will the training interfere, directly or indirectly, with patient-

care activities, and if so, how will this interference be mitigated?

Does the training area have sufficient space to safely practice patient lifts, transfers,

and/or repositioning tasks and other related activities?

Refer to Section 3.6 - Training of the Soteria Strains Safe Patient Handling and Mobility

Program Guide for more information and training materials

Training programs include a process for monitoring and evaluating, or at least auditing, the

effectiveness of the training. This allows instructors to know if participants have learned and

understood the information presented to them. Competence measures for safe work techniques

and use of assessment tools are included with the training material. Participants in any of the

training sessions should also leave the training confident that they know how to apply the

knowledge and/or skills they have been taught.

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The program evaluation framework includes on-the-job observations to verify that participants

from each training session are correctly applying what they have learned when they are

delivering care. During these observations the level of support for using the new knowledge or

skills should be identified. Indicators that physical or organizational barriers are preventing staff

from using new skills/knowledge should also be identified.





Review the process used to identify, prioritize, review, and approve controls to identify if

anything was overlooked or could be improved. This should be done in conjunction with

the unit manager and peer champions. As well, reviewers must ensure that results were

communicated to unit staff and others as appropriate.

Review the process used to plan for the implementation of approved controls to identify

gaps and areas for enhancement. This should be done in conjunction with the unit

manager and peer champions. It is important to ensure that adequate

consultation/engagement opportunities were provided and that the results were

communicated to unit staff and others as appropriate.

Assess how well the plan for implementation of approved controls was followed, if any

issues or barriers were identified, and, if so, how they were overcome. Ensure that the

process used to create and approve required policies and procedures was appropriate

and inclusive.

Verify that all health care workers were provided with training on how to use any

implemented controls. Talk to staff, managers, and peer champions to find out if the

training met their needs and allowed them to safely utilize the control(s). If there are

concerns, then discuss how they can be addressed.

Verify that all health care workers were provided with training on the patient risk profile

and the PACE Assessment tool. Talk to staff, managers, and peer champions to find out

if the training met their needs. Verify that the patient risk profiles and PACE

assessments are being used as intended. If there are concerns, then discuss how these

can be addressed.



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Phase 5 – Initiate Audit Phase

Once a decision has been made to implement a particular control, the implementation process

must be monitored to ensure that equipment is being installed correctly (right equipment, in the

right place, with the necessary accessories, etc.) and the design of new work methods or

processes are effective. After Action Reviews (AARs) are a similar process to safety huddles as

they both involve brief team meetings focused on learning and sharing information. However,

safety huddles typically occur at regularly scheduled intervals (e.g., beginning of shift or hand

over) while AARs occur as a result of an action or activity. Refer to Section 3.4 – Safety Huddles

of the Soteria Strains Safe Patient Handling and Mobility Program Guide for more information.


1. Audit Implementation Progress

Audit progress and success of implementation in priority units

● Program Coordinator with support of unit managers and unit peer champions

2. Identify Issues and Potential Improvements

Identify areas for improvement / additional actions in priority units


3. Introduce After Action Reviews

Plan and execute training for After Action Reviews

Document work policy/procedures as required

Note: After Action Reviews may be introduced as a stand-alone element at any time after safety

huddles have been implemented.

● Unit peer champions with support of unit managers


Document results and report progress to stakeholders

● Program Coordinator with support of HR and/or Communications

Activity 1 - Audit implementation Progress

While continuous improvement activities should be ongoing throughout implementation, this

step is an opportunity to formally review evaluation data and lessons learned. A review of key

performance indicators, previous communications from all phases of implementation, and the

organizational gap analysis should be considered. For an organization, this is an opportunity to

ensure the lessons learned from the current priority areas are applied to improve

implementation/roll-out in other areas. Refer to Section 1.3 - Evaluation and Continuous

Improvement of the Soteria Strains Safe Patient Handling and Mobility Program Guide for more

information.

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Activity 2 - Identify Issues and Potential Improvements

Through the audit process there will be issues such as the use of inadequate or incorrect

equipment, missed training, and incomplete evaluation components. In general terms, the

issues identified will apply directly to a specific unit and how roll-out of the program has

occurred thus far.

Also important during this activity is identifying areas for process improvement. Opportunities to

streamline and improve processes should be identified and prioritized. Process improvements

may be identified that pertain mostly at the unit level; however, they may also apply to

organization-wide processes and/or be applicable to other units and should be captured,

communicated, and executed in a way to be helpful to the organization and other units.

Activity 3 – Introduce After Action Reviews

After Action Reviews are similar to the safety huddles introduced in phase 3; during After Action

Reviews, health care workers immediately assess a situation or event to review what happened,

what should have happened, what accounted for the difference, and what recommendations

could be made for improvement or to prevent a similar event from occurring (or

recommendations to continue/share if the outcome was positive). They may help inform a

formal investigation/root-cause analysis, but should not be considered a replacement for these

processes when an incident dictates the requirement of formal investigation.

An After Action Review is centered around four questions:

1) What was expected to happen?

2) What actually occurred?

3) What went well and why?

4) What can be improved and how?

Teams should be proficient, comfortable, and consistent with executing safety huddles before

introducing training for After Action Reviews. Refer to Section 3.4 – Safety Huddles of the

Soteria Strains Safe Patient Handling and Mobility Program Guide for more information.





Ensure an audit of the implementation to date has been completed includes a review of

relevant evaluation data, progress reports, and lessons learned

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Verify that units are competent, comfortable, and consistent in their use of safety

huddles prior to introducing After Action Reviews

Identify a priority list of issues to be assigned and/or escalated for planning

Ensure training for After Action Reviews has occurred



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Phase 6 – Continue Roll-Out

Phase 6 is essentially a repeat of phases 2-5. New units are selected for implementation and

lessons learned from the early roll-out are incorporated to improve effectiveness and efficiency.

This phase should be repeated until all units have implemented the program. Unit peer

champions and managers from the early units may be called upon to assist with the roll-out by

participating in training new champions and participating in promotion and engagement

activities.


1. Identify Priority Areas (Units)

Identify priority units for initial implementation

● Program Coordinator with assistance from:


and input from the Program Coordinating Committee

2. Identify Priority-Unit Peer Champions

Select unit peer champions for priority units (suggested 2

minimum per unit depending on size and nature of unit)

● Program Coordinator with managers from priority units

3. Conduct Hazard Assessment Training

Train unit peer champions and managers for priority units – hazard assessment module

● Program Coordinator with support of OH&S and/or additional staff

4. Continue with Phases 3-5

Continue implementation on the list of high-priority units as outlined

in phases 3-5

Repeat until all units have implemented the program

● See activities in phases 3-5


Monitor progress and provide updates to stakeholders

● Program Coordinator with support from HR and/or communications staff

Activity 1 - Identify Priority Areas (Units)

The priority list created in phase 2 should be reviewed and a new list of priority areas identified.

Refer to Phase 2 - Identify Priority Areas, for further details on this process.

Activity 2 – Identify Priority-Unit Peer Champions

Once the new priority units have been identified, the Program Coordinator should work with the

Managers from these units to select unit Peer Champions.

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Activity 3 – Conduct Hazard Assessment Training

The peer champions and managers from the new priority units will need to be trained so that

they can properly fulfill their role and responsibilities. A plan will need to be put in place to allow

this training to be delivered in a timely manner. Managers and peer champions from units that

have already implemented the program may be called upon as resources for training and

communicating lessons learned. For more details on this process, see phase 2.

Activity 4 – Continue with Phases 3-5

The new priority units should continue with implementing the program as outlined in phases 3-5

of this document.


The Senior Leader Champion and the Program Coordinator should review the steps outlined in


that have been missed or were considered complete, but not implemented fully. Such as:

New priority areas have been identified

Unit champions have been selected from the new priority areas

Training for hazard assessment has been planned and executed

Phases 2-5 continue to be executed



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Phase 7 – Ensure Ongoing Improvement

When implementing change, it is often thought a program may not require as much effort once it

is up and running. The opposite is true – especially for leaders. To ensure the program has

long-term impact, it is important to:

Provide support post-implementation.

Understand things that just need more time vs. things that need to be modified vs.

issues of simple resistance.

Understand the importance organizational leader’s play in ensuring change is sustained.

Celebrate overall success and milestones along the way.

Phase 7 is where the extra push to transform and reinforce change is undertaken. As well, this

phase is another stage of continuous improvement. The emphasis is on sustaining the

organization-wide and system-level improvements post-implementation.


1. Monitor Program Elements

Monitor elements of safe patient handling and mobility program when implemented in one or more units, as per evaluation framework previously established


2. Undertake Formal Program Review

Conduct a formal review of the program at least once a year after initial implementation


3. Implement Changes as Required by Review

Identify additional organizational and/or system issues that could be improved to reduce the risk associated with patient handling and mobility tasks

● Program Coordinator with support of HR and/or Communications


Document results, identify improvement opportunities, and report progress to stakeholders

● Unit peer champions with support of unit managers

Activity 1 - Monitor Program Elements

Once the program has been implemented in one or more units the emphasis shifts from

evaluating implementation to evaluating processes. In other words, the questions needing

answers change from “How have we implemented the program?” to “How do we improve the

processes?” Many of the specific evaluation questions will be the same or very similar, some

will be new, and others will no longer be relevant. As more units come online with the program,

the monitoring and reporting should reflect these units.

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The monitoring and evaluation framework are designed and implemented in phase 1. Refer to

Section 1.3 – Evaluation and Continuous Improvement of the Soteria Strains Safe Patient

Handling and Mobility Program Guide for more details on the differences between evaluating

implementation and process. It is important to remember at this stage many of the questions the

evaluation framework is designed to address cannot yet be answered. It will take time to get to

the point where outcome questions like “What is the effect on injury rates?” will have an answer.

Activity 2 – Undertake Formal Program Review

A formal annual review is necessary to understand how the program is being sustained and

improved over time. Also, it will assist with transparency and accountability to funders and other

stakeholders. Using the evaluation framework and data collected over the course of the year will

be helpful in learning how the program has been accepted in the organization and help with

identifying unresolved issues and areas for improvement. As well, this formal review allows for a

look at issues that may be having a broad impact on the organization such as accountability

frameworks, data management, funding and/or other related processes.

Refer to Section 1.3 – Evaluation and Continuous Improvement of the Soteria Strains Safe

Patient Handling and Mobility Program Guide for details of what to include in the formal audit.

Activity 3 - Implement Changes Required by Review

Unresolved issues and areas for improvement should be prioritized. Assessing the risk related

to these issues is a good way to prioritize and allows for comparison between other

organizational risks such as financial, strategic, patient satisfaction, care quality, reputational,

and legal if a similar process is used for managing these risks.

Risk-exposure scores can be assigned to each issue or area for improvement. This involves

attributing a number to each issue that ranges from 1-5 in two categories, impact and

probability.

The first category, probability, identifies the likelihood that not addressing the issue will put

individuals (or the organization) at risk.

The second category, impact, assesses the potential extent of the harm that will arise from not

addressing an issue.

The scores can be generated through consensus during a group meeting, by averaging results

from surveys/interviews, or a combination of these.

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Multiplying the two scores for each category (impact and probability) will provide an exposure

score to use in prioritizing how the issues are addressed.

Probability x Impact = Exposure

For reference:

1 = low

3 = moderate

5 = high

Therefore, a higher-exposure score would be prioritized ahead of a lower-exposure score.

There are likely to be issues with high-exposure scores that are complex in nature and/or cost

prohibitive to address. It is important to begin plans for addressing these issues. While this

planning occurs, issues that have a lower-exposure score but are simpler to resolve should be

addressed.




that have been missed or were considered complete, but not implemented fully. They might

ensure:

Monitoring and evaluation is being completed as intended

Formal program audit/reviews are scheduled and completed annually

Issues and areas for improvement identified in the audit are addressed



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