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Join the Falls Prevention Virtual Learning Collaborative
Rapid Fire Team PresentationTeam Call # 3
Name of Presenter: Sheryl L. Courtoreille, RN, BScN, Quality Improvement Coordinator
Name of Organization:Hay River Health & Social Services Authority
Location of Facility: Hay River, NT.
Number of Patients/Residents/Clients:Acute Care – 19Extended Care – 10Woodland Manor Long Term Care - 15
Who We Are
AIM
Team Charter:• Reduce incidence of falls (fall rate) by 40% from baseline by March
2011;• Reduce injury from falls by 40% from baseline by March 2011;• For 100% of inpatients to have a Falls Risk Assessment on
Admission by March 2011;• For 100% of inpatients who have fallen to have a Post Falls
Prevention Injury Reduction Assessment completed by March 2011
Percentage of falls causing injuries – 41%Percentage of patients with completed falls risk
assessment on admission – 30%Percentage of patients with completed falls risk
assessment following a fall – 0%Percentage of “At Risk” patients with a
documented falls prevention/injury reduction plan – 20%
Baseline Data
Team Members
Sue Cullen, CEO – Executive Sponsor
Sheryl L. Courtoreille - Quality Improvement
Coordinator (Lead Contact)
Alex Simms – Occupational Therapist
Jonathan Kennedy – Rehabilitation Aide
Becky Boden, RN – Home Care
Barb Holland, RN – Acute Care
Evelyn Hempal, LPN – Long Term Care
Change Ideas
Falls identifiers for “High Risk” clients to be:
• in the Care Plan;
• outside client room;
• at head of client bed;
• a yellow star label on spine of the client chart at the
nursing station; and
• yellow arm bands (TBA).
MeasuresThere is no direct measurement that is related to our AIM by doing this actionWe are not there yet but we will be there soon!
Comments from clients:• “pretty star”• “how true!”
Comments from Staff:• no resistance to doing this action• staff are recognizing the symbol and implementing identifiers on their own
Measure:• To have 100% of our “high risk” clients identified
Lessons LearnedWhat advice would you give to other teams?
•In order to implement one change, you may need to do a lot of work and implement other changes to get to your original change;
•Ensure any changes/improvements to documentation is realistic;
•Don’t underestimate the education component;
•Start educating and informing staff of what you are trying to accomplish from the start of the project – may help with buy-in.
Key Insights:•Keep your Senior Management Team and Management Team abreast of what you are working on
What were some barriers?• Staffs’ attitude towards changes and/or the idea of change;• Staff lacking education in Falls Prevention Program and its
importance; and • Time needed to dedicate towards this project.
How did you move forward?• Had complete buy in from the Manager of Acute Care & CEO;• Education came in the form of staff meetings with the Manager
and one of our team members;• Both were able to field questions and comments from staff; and• Weekly meetings at a standard time to keep on track.
Challenges
1. Testing a Falls Prevention Injury Reduction Worksheet• Combined the Admission Falls Assessment and Post Falls Assessment onto one
sheet;• Reformatted the Morse Falls Assessment so 5 assessments can be completed
on 1 page;
2. Trialing “Bathroom” signs in the client’s rooms on the bathroom doors;3. Defining a “Toileting Protocol”;4. Transfer card implementation on Acute Care5. Transfer belts in every client room6. Allow time to pass to survey/audit changes and improvements7. Educate, educate, educate!
Next Steps
Name: Sheryl L. Courtoreille, RN, BScN., Quality Improvement Coordinator
Email: [email protected]
Phone Number: (867)874-7168
Contact Information