1. Evercare Quality Improvement Awards Falls Reduction Program
Susan E. Harris, CRA, ADC, LNHA
Assistant Executive Director
Daughters of Israel
West Orange, New Jersey

2. Faculty Disclosures:
Ms. Harris has disclosed that she has no relevant financial relationship(s).

3. Learning Objectives
By the end of the session, participants will be able to:
Objective 1 Understand the importance of multi-pronged interventions
Objective 2 Understand the relationship between falls patterning and the decrease of falls
Objective 3 Understand how program model can be replicated
Objective 4 Understand how the falls reduction model can be utilized to affect change in other areas

4. Facility Demographics
Daughters of Israel
West Orange, New Jersey
Total # of Beds = 303
6 separate nursing units
Inclusive of Alzheimer’s and End Stage Units
Type of Ownership = Non-Profit

5. QI Project Falls Reduction Program
Description of Problem- Falls were significantly higher than others in country, region, state
Additional compounding problems
Falls Quality Indicator at 91st Percentile
Fall Rate = 13.34; Industry standard = *4.16
Based on historical performance trends
Objective – Develop a Performance Improvement team to reduce resident falls by 10% annually
*Per study published by L. Rubenstein, et al, in materials distributed by CMS at a QI training seminar, Baltimore, MD, May 2000
We had 1119 falls in May According to the fall rate that we used we should have had no more than 450 falls annually.
Compounding problems:
2nd oldest population in our state
Dementia population of 63%
Statistically this meant that we could expect to have a higher than average number of falls
Standardized Fall rate formula: total number of monthly falls divided by the total number of patient days times 1000

6. Project Timeline Project began – May 1999 Planning & Implementation
Falls committee met twice weekly, then weekly
Reported to CQI weekly
Currently audits reported at CQI
Planning & Implementation
Core of program developed over 4 years
Various components added after that time
When did project end?
The reduction of falls is an ongoing process
Monitoring, evaluation and CQI reporting continues today

7. QI Planning & Implementation
Leadership
Falls Sub-committee of members included staff close to the problem
Team Work
Team analyzed falls and determined what could be done to reduce them
Data collection tools developed
Communication
Project introduced through care plan team meetings; in-service education
Results communicated to staff through
Team meetings
In-service education
Posted QI studies

8. Falls Sub-Committee DON Charge nurse Floor nurse Nursing assistants
In-service coordinator
MDS coordinator
Activities staff
Alzheimer’s Unit Director
Physical therapist
Social worker
Dietician
Medical Director
Administrator
Quality Assurance Director

9. Falls Reduction Program Issues Encountered
Tried falling leaf program briefly but too much was involved
Tried developing a definition of what is a fall which didn’t make any difference in what we were looking to accomplish

10. Tools Used to Affect Change
Computerized falls tracking system to identify
Unit
Time of fall
Ambulatory status
Use of side rails
Use of restraining device
Any injury incurred
Staff involved
Shift
Expanded to look at other relationships with falls
This early tool helped us to understand where, how and why our residents were falling
Other relationships with falls
Psychosocial
Environmental – cluttered room, overly shiny floors
Patterning – when did the fall happen? Had it happened this way before?
Medication usage – when was a psychotropic medication dispensed in relation to the time of the fall or same for diuretic

11. Tools Used to Affect Change
Data on the patterning of falls
Developed a weighted falls risk assessment – at specific score CP required
Policies and Procedures for Falls Reduction Program
Changed incident report to better collect needed data
Back page included list of investigation points to cover
Today divided into 3 columns to improve data collections and understanding
Falls Care Plan Book – interventions listed by reason for fall
Created Falls Tracking System
Staff Education
Falls Investigators
QI audits of falls care plans and changes made to them per fall
Incentive programs for units with the lowest number of falls monthly
Tracking system is reported monthly to CQI – covers by resident, by unit and fall rate by unit and the overall house fall rate

12. Facility Expenses The cost to us to reduce falls is minimal
$1500 covered
educational seminars,
travel to seminars
Planning and implementation for all staff involved approximately 654 hours per year

13. Resident Outcomes Prior to Program Falls QI 91st to 95th percentile
Fall Rate = 13.34
Average of 1119 falls annually
Today – 2008
Falls QI 37th percentile
Fall Rate = 4.16
Average of 398 falls annually
Fall Rate of 4.16 is at the benchmark and meeting our goal
Use a very basic rule: we should do everything reasonable to prevent a fall, do everything reasonable to prevent future falls and have the documentation do support this

14. Regulatory Outcomes No deficiencies for falls
Surveyors not looking as hard in this area
Falls QI is low
Compliance with regulatory codes has increased

15. Improved Quality of Service Outcomes
In the first 4 years of this program dropped
our fall rate by 59.2%
Staff follow-up for care plans and intervention changes went from 0% accuracy to 95% accuracy
Exceeded 10% goal
Restraint use has not increased
Fall related fractures has decreased
Met national benchmark

16. Enhanced Staff Performance Outcomes
Improvement on:
Investigation of falls
Understanding patterning/causal factors
Trained to pay attention to observable facts surrounding a fall
Immediate response to care plan for updates
Understanding when to change or add interventions
Understand importance of immediate intervention
Care Plans no longer state “will not fall” , “Will not have any injury”
Retain personhood
Activities are crucial
Good communication with families in regard to a fall

17. Improved Organization, Management Structure and Systems Outcomes
Entire process changed centralized at CQI to decentralized on units
Fall Management is a priority for everyone
Chair and bed alarms are overused or misused – changes in intervention use
Weekend supervisor now begins investigation at the time the fall occurred
All shifts trained on falls prevention
Nursing assistants held accountable for falls interventions
All CP and CNA CP updated at every fall
Interventions in place earlier at admission, readmission, unit or room change
Response at one fall or to high risk assessment score
No longer document care plan remains same – change what isn’t working
Starts prior to admission
Tracking system used for falls carried over to skin tears and bruises
Investigation process now used to investigate abuse allegations
Prior to program the resident may have fallen multiple times before any interventions were applied

18. Financial Outcomes
Average hospital charge for fall related injury $11, (Nurse Practitioner, March 2002)
Decreased rate of emergency admissions to hospital
Most recent Evercare rate = 77 admissions per 1000 member years; one of lowest in country
QI New Fractures declined from 67th percentile in 2002 to 38th percentile in 2007
Results in less need for post fracture care

19. Closing Thoughts
Replication of Model – inexpensive to set up; easy to implement; mostly requires staff buy in and understanding that it is a priority for all
Lessons Learned – It is not any one intervention that made a difference but instead the use of a multi-pronged attack of the problem and using multiple interventions at one time.
Insights –
Not all falls can be prevented must also look at what can be done to minimize severity of injury
Questions?
Multiple interventions instead of just trying one approach at a time
chair alarm, non-skid floor strips, a specific activity intervention and a toileting plan might all be applied at the same time
More Insights - As we have come through this project we have learned that the best way to serve our population is to minimize “staff fall failures”. To accomplish this staff must:
be properly educated on falls
Have the proper tools to do their jobs
Understand the importance of educating and communicating with families in regard to falls
Have the skills to report a fall to the family
Trained to devise and implement appropriate follow up and care plan change
Complete a thorough fall investigation
Document accurately and timely
Make reduction of falls a priority for all staff
We created an interdisciplinary approach in which all levels of staff were invested. No one intervention, one idea, or one discipline made the difference by itself.