1. Falls Prevention & Excellence using quality data & communication to reduce falls
May 2017
Kelley Lennon

2. Falls Prevention Program in HNE
Background to program
Aim & method of program
Tools used to support program
Results

3. Background
Approximately 350 falls per month occurred in 2014 across Hunter New England Local Health District.
A significant number of falls involved injury with the number of SAC 2 incidents consistently above benchmark standards.
Introduction of HNELHD patient falls monthly report to assist in the identification of strategies for improvement
A falls reduction pilot project was developed in response to this information

4. Patient Falls Report
Developed to provide a global view of the patient fall situation across HNE (commenced Jan 2015)
Initially provided the following statistics:
Number and type of fall (injury/ nil injury)
Age, location, time and activity undertaken at time of fall
Units with high number of falls
Refined to provide detail around actions to prevent falls, particularly around corrective actions

5. Falls Reduction Pilot project
Meeting Title Here (on Notes Master)
Falls Reduction Pilot project
Aim:
 To reduce falls across HNELHD by 20% in a 12 month period.
Method:
Pilot project conducted from 1st Sept 2015 – 30th Nov 2015
Targeted units within 5 facilities across HNELHD – Armidale, Belmont, John Hunter, Maitland and Moree which were identified in the HNE Patient Falls report as recording higher than average number of falls
Internal Excellence Coach Model
Introduction of new or modified tools
Strengthened accountability within local facilities
© Studer Group®

6. Tools to support program
**rationale for revised documentation was to reduce the volume of documentation, by removing duplication & encourage specific clinical documentation through critical thinking

7. Embedding existing tools:
Risk assessment identification and care planning – Adult Inpatient risk Assessment Form
Hourly rounding with patients – modified for pilot
Bedside Clinical Handover
Patient care Boards
HAIDET / ISBAR

8. Introduced tools: Safety Huddles Common cause/special cause tool (CCA)
A brief team meeting to identify patient risk
Common cause/special cause tool (CCA)
To record fall details and identify patterns
Lean 5 Whys
Question asking technique used to unravel the root cause of falls

9. Huddle for Safety
Improves communication of & focus on safety issues for oncoming shift
Consistent communication of patient risk
Shares individualised risk reduction strategies with whole team
Stand up, preferably around EPJB
5-10 minutes prior to or after bedside handover

10. A C T Huddle Framework Criteria Pt Names/Bed Number Assessment Issues:
High Falls Risk
Pressure Injury Risk
Clinical Risk C
Cognitive Issues:
Confusion/ delirium
Anxiety
Impulsiveness T
Treatment/Care Tactics:
2nd Hourly Toileting
Assist mobility
Falls Mat
Nurse special

11. Huddles

12. Common Cause Analysis Tool
Need to customise for each department
Completed by T/L at time of fall
Can be used to assist reporting incident details
Visual indication of commonality/variations and opportunities for improvement
Used at Huddle to connect staff to causation behaviours
Creates focus for Leader Rounding with staff & patients

13. Common Cause Analysis Tool

14. The Importance of asking Why?
Interpretation of data
Actions

15. The 5 Why’s
5 Whys is an interactive question-asking technique used to explore the cause-and-effect relationships underlying a particular problem.
The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question "Why?" Each question forms the basis of the next question.
The "5" in the name derives from an empirical observation on the number of iterations typically required to resolve the problem.

16. Results of the pilot
Overall the results for patient falls has been positive with:
• An overall reduction in patient falls by 23.3% from January 2015.
• 100% reduction in SAC 1 incidents and 19.2% reduction in SAC 2 incidents
• Reduction of 1.1 falls per 1,000 occupied bed days
• 29% reduction of patient falls in pilot units
The falls numbers collected during the pilot period were compared to the previous 12 month average for each chosen unit. All targeted units showed a reduction in their falls numbers during this period.
The average falls reduction percentage for all areas are:

17. District Results

18. Falls reduction Strategy/Program in HNELHD
Nursing & Midwifery Services to develop resources and provide support to health services
4 days workshops for Internal coaches to develop skills which will support the implementation of the falls program
Internal Coaches at the local level to provide education and coaching to frontline staff
Building internal capacity, identifying champions and local education team
Coaching
Executive Director, clinical services nursing and midwifery, executive sponsor
GMs to provide sponsorship at a service level
DON to led program at local level
NUMS to provide leadership and accountability for frontline staff
Educators to support staff to understand strategies
Allied Health to support staff and consumers in Falls prevention strategies
Patient safety officer to support data collection
Leadership
Falls Prevention Governance committee provides direction to the program in:
implementing strategies
identify gaps and actions
review falls data
validate outcomes
Governance