1. Join the Falls Prevention Virtual Learning Collaborative Falls Virtual Learning Session # 4 & Closing Congress Team Rapid Fire Presentation Template Name of Organization: Alberta Health Services (AHS) Name of Speaker: Ray Johnson & Elaine Demeule

2. Manoir Du Lac (McLennan AB) : 13 continuing Care, & 31 DSL (Designated Supportive Living); and J.B. Wood (High Prairie AB) : 36 Continuing Care Beds & 1 respite Alberta Health Services (AHS): North Zone

3. Team Members Team MemberRole Patricia BaconSenior ‘s Health Area Manager North Zone AHS. Project sponsor Elaine Demeule Care Manager – J.B. Wood Collaborative Leader Ray JohnsonDirector of Care and facility Manager - Manoir Du Lac Bilna JoseStaff Registered Nurse Susan Vanden BoschStaff Registered Nurse - Homecare Rose Marie FiddickStaff LPN Homecare Donna OueletteQuality Improvement Consultant

4. AIM Improvement Objective: To reduce the fall rate and fall with harm rate by 40% by implementing evidenced informed standards in regards to fall prevention and management by the end of the virtual collaborative May 2011. Overall aim: To build a reliable process to ensure that all of our residents/clients are screened for their fall risk, with additional interventions and individual care plans implemented based on the resident/client fall risk to prevent and/or to minimize fall with harm falls for 100% of our residents/clients.

5. Change Ideas Standardization of process – PDSA cycles: 1. A fall risk assessment will be completed on the next patient admitted. 2. A fall risk assessment will be completed on the next two patients that fall 3. A fall risk assessment will be completed on the next admission and the next patient that falls using an alternate FRA tool 4. That the residents fall risk score will be communicated to the staff at shift report, email, and in the communication book 5. The staff will do a resident check every 30-45 minutes on 3 residents who are at the highest fall risk to see if this makes a difference in the frequency of falls. 6.That the staff will try hourly rounds and ask the residents: do you need to go the BR? Are you having pain? Is all your stuff within reach? Staff will give feedback on this process and document that they have completed this process.

6. easures

7. Lessons Learned Lessons Learned/Key Insights 1. Standardize the process and address the WHY! Use the Post fall huddle process as a mini root cause analysis to gain an understanding about WHY the resident fell to implement interventions to prevent further falls. and/or harm from falls 2. That communication is very important with any change….use as many modes for communication as possible. 3. Communicate to and Involve all stake-holders with a big emphasis to include front line, and the resident.

8. Next Steps Key Sustainability Steps/Plan:Target Dates Include the supportive living residents in the process. Start with a FRA on admission, and then after a fall. Monitor their fall and fall with harm rate monthly Initiating : Immediately have 18 supportive living beds on site. That a standard fall risk logo is implemented and is visual for all residents at risk for falls. March 31, 2011 Continue to measure the process and outcome. Fall rate/1000 patient days, Fall with harm, Fall risk assessment on admission and after a fall…..(Measures # 1, 2, 3 & 4) On-going

9. Ray Johnson – Manoir Du Lac (McLennan AB) mdlnm@integratedlifecare.ca mdlnm@integratedlifecare.ca and Elaine Demeule – J.B.Wood (High Prairie AB) elaine.demeule@albertahealthservices.ca elaine.demeule@albertahealthservices.ca : Contact Information