Rapid Fire Team Presentation Name of Presenter: JoAnn Pelletier-Bressette

Falls Facilitated Learning Series Name of Organization: Waypoint Centre for Mental Health Care Location of Facility: Penetanguishene, Ontario Number of Patients/Residents/Clients: 312 bed psychiatric facility Who We Are

Falls Facilitated Learning Series AIM 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

Falls Facilitated Learning Series Team Members Deborah Duncan – VP Regional Programs & Executive Sponsor JoAnn Pelletier-Bressette – Nurse Manager Geriatrics & Team Lead Debbie Branch – Occupational Therapist, Dual Diagnosis Program Kim Dunn – Nurse Educator, Provincial Forensics Maureen Thornton – Nurse Educator, Concurrent Disorders Sherrie Fournier – Patient Safety/QI Coordinator Lee Livingstone - Pharmacist

Falls Facilitated Learning Series Current Falls Prevention Program in place: Policy Screening & Intervention Tree Falls Screening Tool Falling Leaves – visual tools

Falls Facilitated Learning Series Hospital Wide Measures Waypoint Centre has been collecting data since November 2010, with all programs reporting on the following four components: 1.Falls rate per 1000/patient days 2.Percentage of harmful falls (severity 1-4) 3.Percentage of patients with completed falls risk assessment on admission 4.Percentage of at risk patients with a falls prevention / protection intervention in place

Falls Facilitated Learning Series FFLS Program & Measures % of falls causing injuryFalls / 1000 patient days 8 patients from our Geriatrics Program identified as high risk fallers, used as the FFLS study group Changes in data not reflective of hospital trends only episodes of falls in the study group While the study group is not reflective of our total hospital population, the Geriatrics Program is our highest falls risk group Results (to January 1012):

Falls Facilitated Learning Series FFLS Measures Percentage of "At Risk" Residents with a Documented Falls Prevention/Injury Reduction Plan Percentage of Residents with Completed Falls Risk Assessment on Admission No run chart available –at 100% with study group

Falls Facilitated Learning Series Review Falls Change Ideas tested to date in your organization Ideas tested within the Organization Completed?Facilitators/Barriers identified Chart Audit/reviewCompletedYes Validity StudyCompletedYes

Falls Facilitated Learning Series Validity Study Measures Process: – Four charts selected from three programs – Following data reviewed: Heath care providers admission assessment Any referral information from other sources Medication prescribed on admission “A” form Any other information on the file within the first 72 hrs of admission – Scoring of blank tool completed without knowledge of the actual score recorded on admission – No record would be kept of actual name or CB number of pt. – 8 patients already audited on GSP were excluded from tool validation

Falls Facilitated Learning Series Validity Study Outcomes

Falls Facilitated Learning Series Validity Study Key Findings & Recommendations Key findings 92% of patients had a falls risk screening completed within 72 hrs of admission 50% of the time, original assessor/auditors findings fell into the same range. Of these…. 3 out of 11 patients(27%) would not have received interventions for falls risk as one of the 3 falls risk screening tools completed identified a score within the green range Difficult to determine if all information was available to original assessor in order to do a complete assessment Recommendations: Regular communication to staff ensuring 100% compliance with policy Evaluate opportunity for use of a quick screen tool Collaborative approach to the completion of the falls screen Clarification on terminology used on screening tool Communication of findings from validity study related to the compliance and validation processes Policy update, including completion of screening tool at first clinical

Falls Facilitated Learning Series Chart Audit Measures Process: – 8 charts audited: all Geriatric patients within the FFLS study group – Independent auditor used to audit charts

Falls Facilitated Learning Series Chart Audit Key Findings & Recommendations Key findings Kardex main communication tool for visual falling leaf program Falls Screening Tool consistently completed inaccurately, including wide range of different items to be scored. However….. No one was screened lower than the chart review/tool screened as per data provided. This was great as every patient was a high risk, and did require and receive interventions to reduce risk of falls Understanding of scoring the protective factors is not clear Fear of falling due to high shine floor Recommendations: Provide definition /clarification on each item of the screening tool Policy update Review use of gloss finishes on floors

Falls Facilitated Learning Series Lessons Learned on Sustaining Falls Improvement Work during Action Period What advice would you give to other teams? Team commitment to the initiative up front Action on the low hanging fruit Share successes across the organization Learn from other teams’ success and challenges

Falls Facilitated Learning Series What were some barriers? Competing priorities within the organization leading to time and resource constraints Great falls screening process in place – identifying areas of opportunity What are some facilitators? Strong falls intervention strategies already place Strong commitment to falls reduction How do you propose to move forward? Refining of the screening tool and policy 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 Pilot study of Quick Screen Tool Pilot quick screen on key programs Chart audit of completed quick screens during test period Summary of findings Present to FFLS group. April 2012FFLS TeamAudit review Review collaborative approach to completion of screen Bring forward for discussion at Hospital Wide Risk Review Team Meeting March/May 2012Lead, Falls Risk Committee Improvement of Scoring on Follow-up Validation Study Clarification on screening tool Develop Definition / Clarification Sheet for items on screening tool April 2012FFLS TeamIndependent Audit Reviews

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 Floor wax use Review Universal Falls Risk Reduction Strategies: Safe Practice Standards April 2012 Team Lead, Falls Committee Upon approval, implement Policy revision -Modification of policy to reflect above changes (inpatient, outpatient) -Policy review/approval May, 2012 Other dates TBD depending on policy approval/timelines FFLS TeamTBD EducationE-learn R Review/Modification Explore other educational opportunities May 2012FFLS Team Program Quality, Risk and Safety Committee Team Leads Develop standard for yearly review by all clinical staff

Falls Facilitated Learning Series Name: JoAnn Pelletier-Bressette Phone Number: X2116 Or Name: Sherrie Fournier Phone Number: x2787 Contact Information