1. Join the Falls Prevention Virtual Learning Collaborative Falls Virtual Learning Session # 4 & Closing Congress Team Rapid Fire Presentation Template Name of Organization: Hay River Health & Social Services Authority Name of Speaker: Sheryl L. Courtoreille, Quality Improvement Coordinator

2. Location of Facility: Hay River Health & Social Services Authority Hay River, NWT Number and type of Patients/Residents/Clients: Who We Are Number of Patients/Residents/Clients: Acute Care – 19 Extended Care – 10 Woodland Manor Long Term Care - 15

3. Team Members Team MemberRole Alex SimmsOccupational Therapist Jonathan KennedyRehabilitation Aide Becky BodenRN – Home Care Barb HollandRN – Acute Care Sue CullenCEO & Executive Sponsor Sheryl L. CourtoreilleQuality Improvement Coordinator – Team Lead

4. AIM From your Team Charter: Reduce incidence of falls (fall rate) by 40% from baseline by March 2011; Reduce injury from falls by 40% from baseline by March 2011; For 100% of inpatients to have a Falls Risk Assessment on Admission by March 2011; For 100% of inpatients who have fallen to have a Post Falls Prevention Injury Reduction Assessment completed by March 2011

5. Change Ideas List Changes you have tested during Falls VLC PDSA Cycles: Implement Morse Falls Assessment on every client admitted to Acute Care Identify clients who are at “high risk” for falls on the Acute Care Unit (yellow arm bands on clients, notation in Care Plan, “falling star picture outside of client’s room and over their bed, star picture on spine of chart). Format Morse Falls Assessment to allow for multiple assessments on same page for easier trending Institute a “Falls Prevention Injury Reduction Worksheet” Transfer status cards on every client in their rooms Transfer belts available in each room Signage for washrooms on every door on Acute Care

6. Measures MeasureBaseline (October 2010)Final (February 2011) % of falls causing injury 41% ¹ 25% ² % of charts with completed Falls Prevention Assessment 30%100% % of Clients with completed falls risk assessment following a fall 0%100% Percentage of “at risk” clients with a documented falls prevention/injury reduction plan 20%100% ¹ 17 falls in 3 months with 7 being Severity Level 2 ² 4 falls in last 3 months with 1 being Severity Level 2

7. Lessons Learned List any “key” advice or insights you would like to share with other teams? Lessons Learned/Key Insights Any change worth while doing will take time – don’t get frustrated if one change takes weeks if not months to develop Ensure the changes/improvements to documentation is realistic. Ensure you put in time and energy into the development and implementation of the education component of the program. Have someone from outside the core group to look at what you are doing and have them provide feedback – positive and negative. Have a set time every week (month) to meet to keep on track. Keep your Senior Management Team up to speed about your program. Give credit where credit is due.

8. What are some things you will do to sustain the work on reducing falls and injury from falls and by what date? Next Steps Key Sustainability Steps/Plan:Target Dates Develop educational modules for the nursing staff on Acute Care on the Falls Prevention Injury Reduction Program April 1, 2011 Auditing the charts/unit for compliance re: identifying “high risk” clients Will perform audits monthly (beginning April 2011) then quarterly Provide feedback to the staff of Acute Care re: their successes and areas of improvement on program Will provide feedback after audits are completed

9. Name: Sheryl L. Courtoreille, Quality Improvement Coordinator Email: sheryl_courtoreille@gov.nt.casheryl_courtoreille@gov.nt.ca Phone Number: (867) 874 – 7168 Website: www.hrhssa.orgwww.hrhssa.org Contact Information