1. Rapid Fire Team Presentation Template
Name of Presenter:
Dania Versailles, M.Sc.N

2. Who We Are Number of Patients/Residents/Clients: 300 beds;
2700 births per year;
emergency consults
1500 employees et 300 physicians.

3. AIM 20 % reduction in the fall rate;
20 % reduction in the rate of injuries from fall
100% compliance of patients with completed fall risk assessment on admission;
100 % compliance of at risk patients with a documented falls prevention plan

4. Team Members Linda Lessard, Executive director quality and safety
Dania Versailles, clinical nurse specialist: Team leader
Madeleine Lauzon et Josée Berends, clinical educators
Renée Morissette, team leader of a medecine ward
Sylvie Denise Nault, clinical manager

5. Review Falls Change Ideas tested to date in your organization
Changes Implemented within Organization
Working/Not Working
+ Facilitators/ - Barriers identified
Mobile bed exit alarm use
Working
+ Small gains; practical instructions
Friendly and appropriate use;
Availability and direct support for staff;
Support from manager.
Major revisions to our falls policy & procedures
+ Support from internal/external partners;
Networking and awareness or outreach visits
Interactive training sessions /sector (1,5-2 H)
+ Clinical educator and manager commitments;
- Number of sessions, , limited resources and short-term impact on practices

6. Review Falls Change Ideas tested to date in your organization
Changes Implemented within Organization
Working/Not Working
+Facilitators/-Barriers identified
Medical record audits/unit and reporting results to managers
Meditech Monthly reports on falls and injuries (# falls/unit
Working to provide a snapshot of current practice to managers and program lead
+ Promote meaningful discussions & communication;
Promote staff commitment and support staff to implement care adjustments for patient.
-Provide limited insights regarding root causes.

7. Review Falls Change Ideas tested to date in your organization
Changes Implemented within Organization
Working/Not Working
Facilitators/Barriers identified
Monthly workgroup meetings
Working
+Provides a regular forum to exchange information and make decisions
Meeting with medicine’s Quality team:
Action plan 2012;Target: November 2012;
Posters for patients’ washrooms (approved mi-Feb & purchased)
Not yet known
+ Support from other key stakeholders & departments
+ Involvement of additional resources;
+ Optimal opportunity to integrate sustainability initiatives
Changes Implemented within Organization
Status
Facilitators/Barriers identified
Monthly workgroup meetings 
+Provides a regular forum to exchange information and make decisions
Meeting with Quality medicine team:
Action plan 2012;
Target: November 2012;
Posters for patients’ washrooms.
+ Mobilization of additional resources;
Best momentum for sustainability

8. Review Falls Change Ideas tested to date in your organization
Changes in progress within Organization
Working/Not Working
+Facilitators/
-Barriers identified
Create a reference binder (paper and electronic formats)
Working (anticipated)
+Tools box;
+Restraint alternatives;
+Decision tree post-fall
+SBARR communication worksheet
- Limited available resources
E-documentation project (Meditech screens revised for Morse scale, restraint)
Working
+Support from short term project;
Led by nurse with IT expertise and team composed of front-line staff
Development of a business plan for purchase of integrated bed exit alarm
(approved)
+ Supported by 3 directors, technical services, purchasing services and working group
Launch date: postpone to March 2012

9. Measures Any measurement you have related to your AIM
Audits of medical records and reporting results:
Injury rate from July to Dec 2011: 30% to 18%.
Audit show an increase completed Morse scale from 35% to 65% on a medicine floor
100% of at-risk patients had selected interventions documented
Meditech reports (# Falls number and injuries/unit/month);
Feedback of working group members and employees:
“Great that we are working on the solutions and practical tools for patients and staff”
Number of strategies implemented: 11

10. Lessons Learned on Sustaining Falls Improvement Work during Action Period
What advice would you give to other teams?
The PDSA are very important;
Keep the champions and teams involved, informed of the activities;
Use existing standards & expectations as leverage (Accreditation Canada, organizational mission and strategic plan) as parts of accountability;
Create a supportive environment aligned with objectives and additional activities
What are your key insights?
Visibility, presence and involvement of the team for the fall prevention program;
Partnerships and networking at various levels (internal and external)

11. Challenges to Sustaining Falls Improvement
What were some barriers?
Competing priorities
Unavailability of existing resources
Limited or no access evaluation tools and decision-aids
What are some facilitators?
Support from management representatives (middle and upper)
Inter-professional and multi-departmental collaboration
How do you propose to move forward?
Focus on fewer initiatives at a time, integrate RCA and FMEA-type of aids

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
Expand interventions’ set in documentation screen for falls and alternatives to restraints
Convene a sub-workgroup who will:
Make an inventory of causes of falls, by categories
Identify solutions to prevent or protect patients from falls
Integrate them in Meditech & in practice, and follow-up
May 1st 2012
Dania Versailles
# of currently available interventions
# of new available interventions
% of use of new interventions for at- risk patients
# Audits on units to validate reliability of documented interventions.
Staff feedback
Communicate regularly to stakeholders
Obtain a list of expanded communication strategies
Formulate and implement an integrated communication plan
Evaluate outcomes for readjustments
September 1st 2012
# of communications submitted
# of people involved (authors/ speakers, local leaders)
# of visual aids posted/distributed
# of written dcuments produced

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
Post-fall management will become standardized, and efficient
Provide copies of SBARR falls worksheet on units
Orient/coach staff regarding its use
March 30th 2012
Dania Versailles & other nurse educators
Satisfaction or feedback surveys (nursing staff, physician, OT, PT)
Focus group discussion
Have the reference binder accessible to staff on intranet
Submit content electronically to webmaster coordinator
Dania Versailles
Electronic binder is accessible on the intranet
# of hits
Participate in the customization of a new web-based incident reporting tool.
Submit an interest to participate to ensure falls- specific data will be considered and ensure user-friendliness
September 30th 2012
Dania Versailles and other members of the workgroup
Consulted
# of consultations
# of tests completed
Stakeholder feedback
Offer eudcational sessions and outreach visits
Review content as necessary
Deliver sessions/visits
July 15th 2012
Participant feedback

14. Contact Information
Name: Dania Versailles, clinical nurse specialist
Phone Number: , ext:3706