Improvement Associates Ltd. 1 St Joseph’s Hospital & Ridgewood Veterans Wing Preventing Falls Through Staff Empowerment Preventing Falls Through Staff Empowerment Feb. 6/09

Improvement Associates Ltd. 2Background Health & Aging Program consists of 184 Patients housed in two sites. Victory Lane is a 56 bed unit dedicated to Veteran care. X of falls over X months Injury Staff survey indicated lack of awareness of fall risk. Conclusion: Knowledge and awareness of fall risk factors will decrease falls within our patient population. Feb. 6/09

Improvement Associates Ltd. 3 Aim Purpose: To decrease the number of patient falls by 20% by increasing staff awareness and providing education on fall risk through evidence based strategies. Scope: 56 patients on Victory Lane Boundary: Awareness strategies initially limited to nursing staff but later will involve all disciplines. Feb. 6/09

Improvement Associates Ltd. 4 Objectives To heighten awareness of fall risk by introducing a shift change falls awareness report. To increase staff awareness by educating all disciplines on falls prevention best practices. To have staff participate in decision making for future falls prevention strategies. Feb. 6/09

Improvement Associates Ltd. 5 Team Members Jean Dean, RN BN Sherry Gionet, RN GNC© Heather Oakley, RN BN MHS Karen Steen, RN Feb. 6/09

Improvement Associates Ltd. 6 Fall Rate Feb. 6/09

Improvement Associates Ltd. 7 Harmful Falls Feb. 6/09

Improvement Associates Ltd. 8 Patients with Completed Fall Risk Assessment Feb. 6/09

Improvement Associates Ltd. 9 Completed Post Fall Risk Assessment Feb. 6/09

Improvement Associates Ltd. 10 Evidence Based Interventions Note: Interventions include hip protectors, alarms, footwear assessment on patients who fell Feb. 6/09

Improvement Associates Ltd. 11 Residents with Restraints Feb. 6/09

Improvement Associates Ltd. 12 Changes Tested Shift Change Report Non-skid socks Falls Logo Mandatory e-learning Feb. 6/09

Improvement Associates Ltd. 13 Change Cycle Shift ReportEnvironmental Audit Falls Committee Education Falls awareness report adopted Falls awareness report reviewed daily by all disciplines RESULTS:  95% compliance trend > Audit implemented Staff educated and assigned RESULTS:  100% staff use audit tool  100% of room audits completed Awareness & education Supporting champions Implement ideas\barrier s identified RESULTS:  Ongoing changes General education on fall risk ongoing Education on each PDSA cycle ongoing RESULTS:  E-Learning Program Feb. 6/09

Improvement Associates Ltd. 14RESULTS Shift ReportEnvironmental Room Audit Falls CommitteeEducation Awareness Success hinged on creating the will to embrace change and the support provided. Risk report evolved to include taped report Staff 100% compliant since included in taped report It was identified that all disciplines needed to participate Success resulted from staff “buy in”, education and support. Successful in raising awareness of risk amongst all disciplines. Room changes made to reduce risk Success resulted from staff “buy in”, education, support. Terms of reference developed. Learning: All of multidisciplinary team members have a part to play in falls prevention. All staff received falls prevention in service. Staff certified in the Canadian Falls Prevention Curriculum. Sessions created for staff input. Evaluation ongoing Feb. 6/09

Improvement Associates Ltd. 15 Lessons Learned A culture change is required to attain positive outcomes. Maintain the momentum and sustain resources. Falls are multifactorial and require a team approach including all disciplines. Education is more effective when accompanied by evidence based tools. Dissemination of information to all team members is essential. The key to successful programming is to include front line staff when developing and implementing prevention strategies. Feb. 6/09

Improvement Associates Ltd. 16 Next Steps Analyze staff survey to evaluate knowledge change. Disseminate data from post falls assessment sheet and develop new PDSA cycles from gaps identified. Introduce mandatory annual e-learning program. Feb. 6/09