Www.saferhealthcarenow.ca Rapid Fire Template for Teams Facilitator: Dania Versailles, MScN.

www.saferhealthcarenow.ca

Rapid Fire Template for TeamsFacilitator: Dania Versailles, MScN


Falls Prevention Pevention Learning Series

713 Montreal Road, Ottawa, ON. K1K 0T2

Number of patients/residents/clients:300 beds2,700 births a year45,000 ER visits1,500 employees and 300 physicians

About us



Objectives

Based on your team charter:• Reduce fall rate by 20% • Reduce injury rate by 20%• Increase compliance with administration of risk assessment on

admission to 100%• Increase compliance with documentation of a customized

intervention plan to 100%



Team members

Roles and responsibilities of each member in your team

Linda Lessard, Executive Partner, Director, Quality & Risk ManagementDania Versailles, Team Leader, Clinical Nurse SpecialistMadeleine Lauzon and Josée Berends, Clinical EducatorsRenée Morissette, Unit Team LeaderSylvie Denise Nault, Clinical Manager



Review of changes that have been tested at your institution

Changes implemented at the institution

Successful/ Unsuccessful

Facilitating factors (+) and obstacles (-) identified

Use of mobile bed alarm +Small successes; practical and quick instructions; direct support and availability in the units; management support; judicious use

Major P&P revisions: prevention/post-fall intervention

+Support from the various partners/sectors involved (med., MD champion); networking

1.5- to 2-hour interactive training sessions/sector

+Commitment on the part of clinical educators and managers; close and regular communication-Volume of training sessions; lack of staff







Creation of a reference binder (paper or electronic)

RequestedIn progress (launch: mid- January 2011)

Addition of revised P&P collection, toolkits, alternatives to restraints and post-fall decision trees; SBARR

E-documentation project: Meditech pages revised for Morse Fall Scale, restraints,…

(deployment: mid-January 2011)

Subsidized short-term project; overseen by clinical informatics expert

Business plan for the purchase of an integrated bed exit alarm

In progress + Supported by 3 managers (technical resources, procurement and working group)


Falls Prevention Learning Series





Incident/unit audits and communication of results to managers ------------------------Monthly Meditech reports: falls and injuries/units

+Maintain communication with units; commits teams to adjust interventions with patients, health care team

Monthly working group meetings

+ Process catalyst


Falls Prevention Learning Series





Monthly working group meetings

+ Process catalyst

Meeting with Équipe Qualité Médecine (Health Care Quality Team): -2012 action plan-November 2012 targeted-Posters for patient washrooms

+ Mobilizes additional resources to create and sustain momentum; sustainability



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Indicators

Include all measurement indicators related to your objective. These may include indicators measuring your basic data as well as all subsequent data, depending on last submission. They may also include staff or patient feedback.

•Conduct audits and communicate results•Meditech report (number of falls and injuries/unit/month)•Feedback from members of the working group and staff (anecdotal)•Number of initiatives implemented



Lessons learned from work on sustainable and ongoing improvement in falls prevention during Action Periods

What advice would you give to other teams?•Importance of the PDSA cycles (document, assess and adjust planned activities)

•Keep key champions and target teams up-to-date on activities

•Use existing expectations (Accreditation Canada standards; the organization’s mission and strategic plan) as accountability elements

•Create an environment that supports the intended objectives and complementary activities

What are your key ideas?•Visibility, presence and engagement of Falls Program representatives

•Partnership and networking at multiple levels (internal via several sectors and external)



What were the obstacles?•Outdated incident reports; workload distribution; working between meetings; irregular availability of support resources.

What were the facilitating factors?•Addition of resources (pharmacist); working group (monthly meetings); networking with internal and external partners; optimization of existing resources (LEAN Process) involvement of local level at national level; access to Meditech report system for audits/units; SHN and AIIAO support.

What next step would you suggest?•Supporting the addition of the program to the corporate QIP in order to reach other clinical and non-clinical sectors.

Challenges to sustaining improvement in falls prevention



Elements you will work on during Action Period #:

Potentially add the Falls Prevention Program to the hospital’s 2012-2013 Corporate Plan

Integrate falls into daily operational processes: Patient care rounding- Clinical managers (med.) Environmental assessment – Team supervisors (med.)

Communication: caucuses, inter-professional meetings, unit meetings

Next steps



Inform physicians of changes as required Create a post-fall analysis form (using a root cause analysis

approach) Establish a sub-group to develop a flyer for patients and

families Increase practices and resources that offer alternatives to

restraints and revise the P&P with the RNAO’s BPG (to be released in January 2012)

Promote monthly “Non-Violent Crisis Intervention” training (CPI)

Next steps (cont.)



Name: Dania Versailles, Clinical Nurse Specialist

Email: [email protected]

Phone: 613-746-4621, ext. 3706

Contact

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Www.saferhealthcarenow.ca Rapid Fire Template for Teams Facilitator: Dania Versailles, MScN.

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