Changing focus from repetitive screening for Falls Risk to a model that supports Falls Prevention Historically for each new issue addressed, weve added a new section or Tab to HED – not sustainable and adds complexity to documentation Framework developed to identify and address all safety risks efficiently

Pilot focuses on: Falls Risk portion of new Safety Build Other New features that will be addressed: Role/Communication documentation Changes in documentation of Patient/Family education & engagement Changes in Restraint, CIWA, and some other safety-related documentation

RNs complete hands-on check off on documentation and workflow associated with new Falls/Safety HED build Practice Scenario: o Determine the Morse Falls Risk Score o Identify safety risk factors and safety problems ; Start Safety or Restraints Priority Problem, if warranted o Document, Care Interventions, Patient/Family Teaching, and any Notifications & Care Coordination o Document shift goals/outcomes for Safety Priority Problems & response to safety interventions

1. Assess 2. Care 3. Educate 4. Notify Safety Risk Assessment Safety Plan Response to Interventions

Role Communication Section (caregiver contact info)- nurses to document caregivers contact info once and if any phone number changes Education Categories – categorized in similar fashion to Priority Problems

Safety assessment on every patient every shift. Also o 9N: Morse Falls screen on admission & with change in status/condition (e.g. Transfer to different level of care, change in mental status, etc.) o 6A/B: PEWS screen documented q4h (will be moved from Falls/Safety Tab at conclusion of pilot before VCH-wide rollout) Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and others ) will be identified. o If they are a priority, also initiate this as a Priority Problem Safety Interventions will be documented – things you: o Assess/Monitor/Evaluate/Observe o Care/Perform/Provide/Assist o Teach/Educate/Instruct/Supervise o Manage/Refer/Contact/Notify

New Education Tab: Caregivers contact information (Care Contacts) – will be documented in new Role/Communication section Patient/Family Education & Engagement Some other Safety documentation (eg. Restraints) streamlined.

Plan of Care documentation Priority Problems – continue to create and evaluate goals Pathway, Nursing Summary, and Plan Priorities documentation in HED Continue to assign e-docs pathway Education Record tab still visible for pilot until further discussion as to whether to blend the new Education tab with current one Admission History documentation of substance screening and caregiver contact information will still be recorded until further evaluation with pilot

Admission Morse Falls Risk screen Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Beginning of Shift Safety assessment; Identify problems & Plan Interventions Document expected Short Term Goals for Safety Priority Problems End of Shift Start/End Safety Priority Problems if warranted Document Short Term Goal Status or outcome for Priority Problems Document Response to all Safety Interventions Condition/ Status Change Morse Falls Risk screen Repeat other Safety Assessment & Revise Planned Interventions as appropriate

Admission Morse Falls Risk screen Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted Click on HED Train tab and select the Safety Falls/ Risk tab Locate and complete the Morse Falls Risk Section – bottom of screen Complete Safety Risk Assessment

Admission Morse Falls Risk screen Safety assessment as part of head-to-toe assessment; Identify problems & Plan Interventions; Start Priority Problem if warranted How would you assess the patients: Ambulation aid Gait Hover over boxes with HED Upgrade on many fields

Continue to document: Nursing Summary, Plan Priorities, and Goal Status Include from Safety/Falls tab end of shift documentation on: Response to Safety Interventions Start/End Safety Priority Problems if warranted Document Short Term Goal Status or outcome for Priority Problems Document Response to all Safety Interventions End of Shift

Re-Assessment of Morse Falls Risk Screen and Safety Assessment with: Change in level of care (unit-to-unit) Status Change Fall or injury Increased monitoring of patients condition due to status change Condition/ Status Change Morse Falls Risk screen Repeat other Safety Assessment & Revise Planned Interventions as appropriate

Day of go-live also New Safety/Fall Risk tab will replace the old Falls Risk section in assessment tabs New Education tab will appear- old Education Record tab will still be visible Restraints documentation moved from Restraints tab to Safety/Fall Risk tab Past data will be viewable for the Restraints tab, and Fall Risk section but will not contain charting boxes. CIWA tab released

Resources: Super Users – in-staffing Educator Unit Resource Manual- contains issue log, pocket aides, staff& support schedule, and pocket aides Implementation Support SuperUsers SSS/CAPS: 9a-5pm and 9pm to 5am, Sept. 18, 19, 20, 21 st Issues Log on unit