1. 15 CHS & 5 Orthopaedic Patients, 3 DNs, 2 Nurse Managers, 2 Inpatient RNs, ADON used the Safety Thermometer Tool over 13 weeks

2. Good to participate in ST Trial
One page ‘enlarged’ tool relatively easy to use after initial use
Included Clinical Record, PADP, chart review, & time with patient linked to falls in last 72hrs?, PI 3 Step Skin Check, UTI symptoms?
Different time and focus b/w Community and inpatients esp. frail elderly, mobile young pt, high dependency orthopaedic pt.

3. Opportunities & Challenges
Completed by hand - data entered away from practice site
Identified potential to use inpatient care process audits in CHS - currently only inpatient.
ST less value for inpatient due to Practice Audit Schedule - no new harm was identified
Focus on harm on its own not as informative as Care Process monthly audits with continuous improvement focus
Exposed VTE ‘lens’ that will inform current DHB agenda
Catheter focus more informative in CHS than post surgical pt - time focus useful

4. Opportunities & Challenges
Potential for ST Tool with modifications to be used across the Health Care Continuum if no other effective practice measure audits in use
Aspects of tool would be useful to integrate into existing practice audits with improvement – PI prevalence (all not just worst) in monthly PI care process audits
See the value in a national tool but with modifications
? Value as an 6 monthly or annual “national” audit tool
? NSCI - harder to use but provides
more information

5. Point of Care Monthly PI and F prevention and management CP Audits
Captures a snap-shot of practice against 5 care requirements, involves patient partnership as well as instant feedback on missed care enabling it to be addressed.
Care Process Audit: Reinforces practice review and area ownership of improvement focus
What interventions work and how consistently patients receive
these at a clinical area and
organisational level?

8. KPH Wd 4 (Health of Older Person) Falls Report Key Care Interventions
July 2015
KPH Wd 4 (Health of Older Person) Falls Report
Falls count is lower than the previous month
Control Chart Explanation: The control chart shows the falls count in W4 from June 2012 until now. It highlights that the average number of falls per month is 5 however there is quite a large variation (11) in the process (usual practice). The process measure is the difference between the lower & upper control limits. When the chart shows any count total that is outside the lower & upper control limits e.g. not within normal variation - the reason must be investigated.
Practice focus for improvement: To be inserted from falls audit tool as per areas actions or if no comments care interventions in orange.
Key Care Interventions
AUDIT RESULTS
Feb
Mar
Apr
May
June
July
Care 1: Initial falls risk assessment
90%
100%
70%
Care 2: Safe bed space environment
Care 3: Patient/Family aware falls prevention
80%
60%
Care 4: Initial falls care plan documented
Care 5: Falls prevention care plan reviewed
Overall Care Intervention Compliance
50%