Rapid Fire Team Presentation Template Name of Presenter:

Falls Facilitated Learning Series Name of Organization: Churchill Regional Health Authority Location of Facility: Churchill, MB Number of Patients/Residents/Clients:35 Who We Are

Falls Facilitated Learning Series AIM From your Team Charter To learn and integrate strategies of sustainability into our organization’s falls improvement plans to ensure we increase the likelihood of sustaining practice change for prevention of falls and injury reduction while holding the gains over time. We will be active participants in data submission to SHN Falls Intervention and network with other enrolled teams in the National Falls Facilitated Learning Series (FFLS).

Falls Facilitated Learning Series Review Falls Change Ideas tested to date in your organization Changes Implemented within Organization Working/Not WorkingFacilitators/Barriers identified Morse Falls Assessment Scale performed on admission for all patientsand repeated whenever a patient has a fall WorkingStaff need to be reminded to complete a reassessment post-fall Purchased falls sensor (clips onto patient’s clothing) WorkingSome patients take it off

Falls Facilitated Learning Series Measures Falls are calculated on a monthly basis and are included as a part of the Quality/Risk Management/Infection Controlo/Patient Safety Report prepared and presented at the Monthly Board of Directors/Senior Directors meeting. All falls are discussed at multi-disciplinary rounds 3 times per week Incidentreports are completed for each fall, entered in the Incident Report log, with follow-up review weekly and monthly. A Root Cause Analysis is done for patients with repeated falls to identify possible solutions. Regulated professionals and support sites are referred to regularly for their input for ways to support our efforts to reduce falls.

Falls Facilitated Learning Series Lessons Learned on Sustaining Falls Improvement Work during Action Period Continually review all falls to determine cause, identify how the incidents could have been avoided Be sure to have input and support from all members of the multi-disciplinary team (including the pharmacist and physicians) Support the care team by ensuring sufficient staffing levels Provide care equipment required to best support the patients and the staff Performing a Root Cause Analysis is very helpful for problem solving Do Morse Falls Assessment Scale upon admission of all patients Repeat the Morse Falls Scale whenever a patient has a fall Provide education to all staff about falls prevention, discussing tripping hazards, environmental hazards, etc.

Falls Facilitated Learning Series Some barriers include encouraging all staff to remember to perform the Morse Falls Scale assessment and reassessment Reminding all support staff to adhere to a client’s care plan (example- one patient had all trashcans removed from room due to trying to use as a toilet-cleaning staff placed one in the room and patient had a fall) Some challenges include high rate of staff changeover, use of locum staff The Nursing Manager is reminding everyone and is auditing every patient’s chart to ensure the Morse Falls Scale assessment were completed Challenges to Sustaining Falls Improvement

Falls Facilitated Learning Series 6 Month Post FFLS Sustainability Plans for Falls Improvement Work Goal Description (What is AIM) Action (What STEPS are to be taken to achieve) Timeframe (When to be done by) Person Responsible Metrics: What is to be monitored to identify achievement To increase knowledge of falls prevention -Bulletin Board presentation November 2011Patricia LeCompte That it was done-was completed See Above-Story in newsletterFeb, 2012Nancy Hughes Written and printed in newsletter Falls Prevention literature to be distributed Brochure to be developedFeb. 2012Patricia LeCompte Brochure developed and distributed Ensure Morse Falls Scale done on admission Chart AuditsOngoing, monthly basisJulie Hetherington % of charts with completed Morse Falls Assessment Scale Reduce falls of patients with repeated falls Root Cause AnalysisOngoing Patricia Carter-LeCompte with Multi-disciplinary team Reduction of falls

Falls Facilitated Learning Series 6 Month Post FFLS Sustainability Plan (continued) Goal Description (What is AIM) Action (What STEPS are to be taken to achieve) Timeframe (When to be done by) Person Responsible Metrics: What is to be monitored to identify achievement Continue Morse Falls Assessment on all new admissions Staff discussion and follow-up Continually Julie Hetherington, Patient Care Manager Regular audits weekly and monthly. Monitor all falls Support by Quality Director Continually Nancy Hughes, Director of Quality and Planning Report on Monthly statistics.

Falls Facilitated Learning Series Name: Patricia LeCompte, Patient Safety Officer Nancy Hughes, Director, Quality and Planning Phone Number: / Contact Information