Rapid Fire Team Presentation Template Name of Presentor: L.Winnett RN BHScN ADOC

Falls Facilitated Learning Series Name of Organization: Lakeside Long Term Care Location of Facility: Toronto, Ontario 127 Long Term Care, consisting of 4 units of 32 residents each 1 Respite Who We Are

Falls Facilitated Learning Series AIM From Lakeside LTC Team Charter Reduce the fall rate per 1000 resident days from 6.68 to 5.35, a decrease of 20% and maintain this decrease for a period of three months Reduce the % of falls causing injury from the base line by 20% Maintain the current 100% of residents with completed falls risk assessment on admission. (continued)

Falls Facilitated Learning Series AIM (Cont) Achieve 100% of residents who are “at risk” with a documented falls prevention/injury reduction plan from a baseline of 26.98% Achieve 100% of residents with a completed falls risk assessment following a fall or significant change in medical status from a baseline of 20.59% Maintain the number of residents with restraints in place at baseline or below. AIM

Falls Facilitated Learning Series Team Members Team MemberRole Team MemberRole Donna Lee AdministratorTeam Sponsor Lynn Winnett RN BHScNTeam Lead Sudhir Kurup PTTeam Member Ramil Rodreiquez PTATeam Member Barbara Palwicz RNTeam Member Toni David Restorative Aide Team Member Jillbert Racadag OTTeam Member

Falls Facilitated Learning Series Review Falls Change Ideas tested to date in your organization Changes Implemented within Organization Working/Not WorkingFacilitators/Barriers identified CQI log-develop and trial a data collection form that will capture all the relevant data that is needed for falls related reports, ease of trend identification, marked increases or decreases etc. WorkingOnly the person who created the log understand all the terminology and /or criteria behind the different areas of data, therefore needed to include a legend Care Plan updating- Plan was for one person to do a blitz and bring compliance up to 100% Worked, 100% achievedWas not sustained due to factors such as roles not clearly identified, changes to computerization, plan for sustainability was not built into the initial plan

Falls Facilitated Learning Series Review Falls Change Ideas tested to date in your organization Changes Implemented within Organization Working/Not WorkingFacilitators/Barriers identified Created a checklist for the registered staff to se when doing safety rounds that identify the specialized falls prevention needs of individual residents WorkingNothing at bedside to readily identify individual falls prevention items that should be in place i.e. fall out mats, personal alarms, no checklist for charge nurses to easily refer to when doing rounds/checks

Falls Facilitated Learning Series Measures AIM: Reduce the fall rate per 100 residents days by 20% from a baseline of 6.68 to a target of 5.35 Results: Target met in November 2011 but slightly elevated in Dec. Working towards goal.

Falls Facilitated Learning Series Measures. Decrease in the number of witnessed falls by 13 or 44.8% over the course of 2011.

Falls Facilitated Learning Series Measures Decrease in the number of residents who had repeat falls per quarter from a high in second quarter at 19 to a low in Oct. Nov. Dec of 9.

Falls Facilitated Learning Series Decrease in the number of residents who had repeat falls with in the month from a high of 10 to a consistent number of 3 for Sept. Oct, Nov. and Dec. However the lowest level is 1 in March. Measures

Falls Facilitated Learning Series AIM: To maintain 100% of residents with a falls risk assessment on admission Results: A drop in Nov. to 75% indicative of 1 out of 4 admissions not having a falls risk assessment completed Measures

Falls Facilitated Learning Series AIM: Achieve a percentage of 100% for at risk residents with a documented falls prevention/injury reduction plan Results: Based on the decision of the falls prevention committee this area did not become a focus until Nov which lead to the achievement of 100% in December (Series 1 is the number of residents at risk and Series 2 is the number of residents with a plan in place). Measures

Falls Facilitated Learning Series Measures AIM: to reduce to the number of falls causing injury by 20% Results: Lakeside has met its target of 19.2% which would be a reduction of 20% and now we will continue to work towards a new goal of less than 10% of falls resulting in injuries. Measures

Falls Facilitated Learning Series Prevalence of falls risk at Lakeside LTC facility wide as of Oct. 31/2011 Measures

Falls Facilitated Learning Series Measures

Falls Facilitated Learning Series AIM: Maintain the % of residents with restraints at baseline or below the number Results: Lakeside has consistently maintained the % of residents with restraints below baseline for Oct. Nov. and Dec. and below the provincial mean (as per data for FFLS) Measures

Falls Facilitated Learning Series What were some barriers? 1. Recently switched over to computerized documentation resulting in mixed forms of documentation and more of a challenge to follow up. 2. Inconsistent follow thorough from shift to shift What are some facilitators? 1. computerized documentation 2. support of the management Challenges to Sustaining Falls Improvement

Falls Facilitated Learning Series How do you propose to move forward? Goals for 2012: maintain current trend whereby the number of falls related incidents decreases by 20% in 2012 from a total of 284 to 228 or less. maintain current 100% compliance with care planning for low, medium and high risk residents. maintain current 100% post falls analysis and falls risk assessment post fall and change in status reduce the number of falls causing injury by 20% from 15 to 12 (using severity harm scale) decrease the number of falls/FOF on day shift by 50% from 74 to 37 by the end of Challenges to Sustaining Falls Improvement

Falls Facilitated Learning Series Future Projects for Falls prevention program 2012: 1. individual resident bedside cards for falls prevention strategies pamphlet for residents and families to be included in the admission package and handed out to all current residents/families outlining the falls prevention program, what they can do to help us and what we can do to help them 2. target boards for each unit to measure their successes in achieving individual unit goals 3. development and distribution of the Personal Support Workers Falls prevention handbook (courtesy of RNAO best practice) 4. Re format monthly log forms and CQI reporting form to reflect current reporting data and facilitate ongoing auditing and tracking 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 Decrease the number of repeat fallers to zero and maintain this for a period of three months Unit Focus groups for each repeat faller Monthly basisHeaded by falls prevention chairperson and PT Number of repeat fallers per month

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 Decrease the number of falls events occurring on the day shift by 50% Monthly falls prevention committee, Education for day staff, identify possible causes for increased falls on day shift Next six months Falls committee, all days staff, nurse educator, PT, OT Number of falls events occurring on day shift Increase staff, resident and family awareness of our falls prevention program and what their role in the prevention of falls Develop an information phamplet to include in the new admission package, create individualized resident room cards, include discussions at care conferences and every time the resident has a fall with the resident and his/her family Over the next six monthsNursing staff, ADOC,Survey pre and post of current resident/family awareness.

Falls Facilitated Learning Series 1. When you are developing a plan of change make sure to include plans for sustainability from the very beginning. 2.Introduce program changes/targets in smaller pieces for increased staff compliance. 3.Allow the staff to have input into the change process 4.Have clearly defined roles and responsibilities to ensure accountability and completion. 5.A successful falls prevention program requires designated resources to for optimal results to be achieved. Lessons Learned/Key Insights

Falls Facilitated Learning Series Name: L.Winnett RN BHScN ADOC Contact Information