Utilizing The Joint Commission Targeted Solutions Tools: Developing and Sustaining a Fall Prevention Program Kathleen LeDoux MS,RN-BC,CPHQ Performance Improvement Nurse St. Charles Hospital, Port Jefferson, New York

St. Charles Hospital Is a community hospital located on Long Island in eastern Suffolk County The inpatient population is diverse including: Adults Pediatrics Acute Care Orthopedics Bariatrics Critical Care Rehabilitation Maternal Child Health Chemical Dependency Inpatient Rehabilitation and Withdrawal Stabilization Emergency Room Services

Initiatives and Objectives To develop and sustain a fall prevention program that could effectively be implemented across clinical services and diverse patient populations Observation and data analysis revealed we were not consistently implementing fall prevention best practices over time

The Joint Commission Center for Transforming Healthcare Targeted Solutions Tools A year long commitment in a dedicated cohort lead by a Joint Commission Certified Six Sigma Black Belt Utilizing Robust Process Improvement methodology – Design, Measure, Analyze, Improve and Control (DMAIC) To determine “the contributing factors to falls” – leading to a more consistent prevention program

Transformational Leadership 2014- 1015 A creation of a system-wide Fall Prevention Policy and staff education program Standardized documentation in the EHR (EPIC) utilizing IHI Risk for Injury Assessment and MORSE FALL RISK Scale in adults, HUMPTY-DUMPTY Fall Risk Assessment in pediatrics Review of NDNQI definition of falls and injury levels Introduction of a Patient Fall Prevention Agreement Institution of a weekly interdisciplinary fall prevention huddle meeting including the CNO, Director of Risk Management, Nursing Leadership/ Education, Directors of Physical Therapy and Pharmacy and front line staff

Replicability Joint Commission Cohort Unit Participation 20 to 30 falls per quarter were requested for data input utilizing the Joint Commission Data Collection Form 3 Medical – Surgical Units and the Acute Rehabilitation Services would participate All nurse leaders would participate in project education and all nursing units would utilize the TST as the first line of review post fall, followed by a facility developed investigation tool

The Weekly Huddle Meeting Utilizing the information from the TST and SCH Investigation Tool Review all falls which have occurred in the prior week Discuss pre and post fall interventions Enhance Patient-Family education Develop and implement an interdisciplinary Plan of care All participants have an equal voice in the huddle discussion – how the fall occurred, how a future fall could be prevented

Additional Project Design Elements Monthly cohort call led by the Joint Commission Project Leader Six Sigma concepts used to track progress Implementing change Developing stake holder support Utilizing a project contract Falls definitions, severity level education Data entry into TST Implementing the Targeted Solution for contributing factors

TST Solution for Bathroom Assistance Implement hourly rounding with proactive toileting for all patients The 3 Ps (Pain, Potty, Position) Implement scheduled toileting for all high risk patients Set a time limit no more than 4 to 6 hrs go by before the patient is required to get up and use the bathroom Ensure that a member of the staff remains with the patient at all times while toileting or showering Make a commode available to high fall risk patients and store at bedside Encourage patient to use the call light for assistance

Lessons Learned TST and Six Sigma methodology could be applied to all clinical areas of the hospital The approach provided consistency for all staff and unit managers The commitment of the Senior Leadership Team with the CNO and Director of Risk Management attending the weekly falls huddle meeting demonstrates to all levels of staff that patient safety and fall prevention are a primary focus at St. Charles