West of England Academic Health Science Network - launch Preventing Harm from Patient Falls South West Quality and Patient Safety Improvement Programme (Safer Care South West) Improving Safety in Mental Health Collaborative South of England

Patient story “I needed to go to the toilet. I couldn’t find the call bell. I kept calling out for help. Eventually someone came but they went to get a commode and I couldn’t wait. I know I shouldn’t have tried to get out without help. I should have just gone on the sheets in the bed and then I wouldn’t have broken my hip.” Improving Safety in Mental Health Collaborative South of England

Situation Within 18 months: Reduce the total number of inpatient falls by 10% Reduce the number of serious falls by 20% Reduce the number of recurrent falls by 20%

Background 2 large hospital sites Over 9000 staff Over 1000 beds Over 65s is the fastest growing group in population of local area Change in Culture amongst staff

Strategic Falls Prevention Group from Ward to Board Wide membership of engaged staff Matrons, nursing, Medical, Therapy, Pharmacy, Facilities, Audit, Patients Executive Sponsor Pragmatic frontline actions to reduce falls risk on wards Quality Improvement methodology in developing new tools at ward level

PDSA Testing Ramps A P S D DATA FEEDBACK TO FRONTLINE STAFF: Compliance with form completion Cycle 1E: Test form on all patients Cycle 1D: test with 1, 3 then 5 nurses Cycle 1C: modify form with RAG risk levels Cycle 1B: Form modified to link directly with key interventions to prevent falls Cycle 1A: new falls risk assessment form – 1 patient Process Change PDSA: Testing falls prevention bundle 43

Falls risk assessment

Bed safety rail assessment

Scheduled checking

After falls care

Visual cues for staff Involving all staff members and visitors

Posters

How did we do?

Weekly e-audit tool

Pull from neighbouring wards

Falls Rate per 1000 bed days from January 2011 to August 2013 Pilot Ward

Falls rate per 1000 bed days April 2011 to August 2013 Spread Ward

Trust-wide Falls Rate per 1000 bed days from April 2012 to August 2013 27 19

Trust-wide Recurrent falls from April 2012 to January 2013

What worked Working with teams on the ward to test and influence the development of interventions that worked for their patients Regular huddles to keep up the momentum Resisting “Spray and Pray” Leadership at every level

Our achievements Implementation of action-focused bundle across 2 large sites across 18 months with sustained improvement Involved all members of staff in the hospital from Switchboard to phloebotomists We have reduced serious harm from falls in our Trust by 30%

Next challenges Focus on acute confusion assessment of patients Improvement work on medical assessment of falls by junior doctors Measuring blood pressure accurately to identify postural hypotension New hospital!

Recommendation Identify a pilot area with engaged staff Ensure you have baseline data for process measures before testing Get the right team together Set up measurement system early Don’t spread until you have reliable and sustained improvement