1. Fall Improvement Team, Veterans Health Unit
Beth Harris, RNMN

2. Who We Are Name of Organization: Veterans Health Unit
Location of Facility: Fredericton, NB
Number of Residents: 47

3. AIM The AIM of the Falls Improvement Team:
To engage fall prevention/injury reduction improvement team members in the National Falls Facilitated Learning Series (FFLS) to learn strategies and plan for sustained improvement in reducing falls and injury from falls.

4. Team Members
Andrea Stierle-MacNeill, Administrative Director - Executive Sponsor
Beth Harris, CNS Geriatrics – Team Lead
Colleen McNaughton, Nurse Manager
Kelli Macaulay, PT
Mary Ellen Huntley, OT
Janet Crealock, CTRS

5. Review Falls Change Ideas tested to date in your organization
Changes Implemented within Organization
Working/Not Working
Facilitators/Barriers identified
Added Patient Safety Check on Kardex care plan
Working
Staff Compliance
Defined change of status for MFS (using SPICES tool)
Track % of residents with completed falls risk assessment upon admission, post fall and change of status
Weekly Audit Change Sheet
Fall Cross

6. Measures
We have been collecting data since September for this initiative. From the time period September - December we are showing improvements in the following areas:
the percentage of residents with a completed falls risk assessment following a fall or change in medical status.
the percentage of at risk residents with a documented falls prevention/injury reduction plan. (0% to 100%)
This measurement has shown a steady increase in completion rate and now we have achieved our goal of 100%. This was achieved in part with a Horizon wide implementation of a standardized fall risk assessment tool – the Morse Fall Scale (MFS). As a result of several PDSA cycles of change we have targeted brief education sessions supported with posters and MOX messages to remind and reinforce to staff the message to complete the MFS on any significant change in medical status. Using the NICHE SPICES tool as a way to define a change in medical status was another PDSA change cycle that further reinforced the message.
This measurement has also shown a steady increase in completion rate since September and now we have achieved our goal of 100%. This was achieved as a result of several PDSA cycles of change that targeted our MediTech nursing care plan, adding a Patient Safety documented intervention option to the care plan, and educating nursing and PT and OT how to add a fall prevention or injury reduction intervention to this section of the kardex.

7. Measures
To sustain the gains and improvement in the above measures we have embarked on another PDSA change cycle which consists of developing a data collection form to track these gains on a weekly basis.
The percentage of residents with a completed falls risk assessment on admission has remained at 100% since starting the initiative in September.
The Falls Improvement Team will discuss the results at weekly Falls Rounds so interventions and corrective action can be timely and appropriate.

8. Measures
We have not seen improvements as yet in the following measures and are continuing to work to goal:
1. fall rate
According to Safer Healthcare Now the benchmark in LTC is a fall rate of 5.5. We have been consistently over this number since the initiative has begun.

9. Measures the percentage of falls causing injury
According to Safer Healthcare Now the benchmark in LTC is We have been consistently over this number since the initiative has begun. These will be our areas of focus in the project over the next few months as we work to meet our goal of a 40% reduction in these measures over the next year.

10. Lessons Learned on Sustaining Falls Improvement Work during Action Period
Simplify process re. tracking falls and documentation so it can happen in a timely way using a PDSA change cycle to define steps
Decreasing number of times and places falls were documented by staff members
New use of Kardex as a tool to update a falls care plan for individual residents

11. Challenges to Sustaining Falls Improvement
Facilitator – an effective process was already in place to review falls – we had an established interdisciplinary team that met weekly to discuss resident falls
Barrier – Morse Fall Scale is not sensitive enough to distinguish the very high risk residents from those who are at high risk in general. We created a new subcategory to help define who we will identify with visual cues for staff.
How do you propose to move forward?

12. 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
To continue to track core measures using audit sheet and stats from risk management
Fill out form regularly and submit statistics
Ongoing
Resource nurse or nurse manager
Track core measures
To monitor effectiveness of weekly audit
Tool to be completed daily and submitted weekly. Information to be reviewed monthly
Daily, weekly, and monthly as described
Resource nurse or nurse manager to complete form and submit. Clinical Nurse Specialist to review.
Completion and ease of use of tool

13. 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
To use visual cues to define our highest risk residents and to use bracelets for hospital admissions, procedures, or tests
Assessment done by PT to define which residents are at very high risk. Proposal by CNS forwarded to the Regional Steering Committee for endorsement
Committee meets March 14
Clinical Nurse Specialist
If endorsed, it will be implemented
To keep staff informed of falls stats
Information session for all staff; individual feedback for staff from resource nurse
Implement a monthly Fall Cross to provide feed back loop to staff
7 March 2012
1 March 2012
Falls team to present session. Resource nurse to provide feedback
Nurse Manager and Resource Nurse
QI tools visible; information session held
completed Fall cross on each unit

14. Contact Information
Name: Beth Harris, CNS
Phone Number: