1. Utilizing The Joint Commission Targeted Solutions Tools: Developing and Sustaining a Fall Prevention Program
Kathleen LeDoux MS,RN-BC,CPHQ
Performance Improvement Nurse
St. Charles Hospital, Port Jefferson, New York

2. St. Charles Hospital
Is a community hospital located on Long Island in eastern Suffolk County
The inpatient population is diverse including:
Adults
Pediatrics
Acute Care
Orthopedics
Bariatrics
Critical Care
Rehabilitation
Maternal Child Health
Chemical Dependency
Inpatient Rehabilitation and Withdrawal Stabilization
Emergency Room Services

3. Initiatives and Objectives
To develop and sustain a fall prevention program that could effectively be implemented across clinical services and diverse patient populations
Observation and data analysis revealed we were not consistently implementing fall prevention best practices over time

4. The Joint Commission Center for Transforming Healthcare Targeted Solutions Tools
A year long commitment in a dedicated cohort lead by a Joint Commission Certified Six Sigma Black Belt
Utilizing Robust Process Improvement methodology – Design, Measure, Analyze, Improve and Control (DMAIC)
To determine “the contributing factors to falls” – leading to a more consistent prevention program

5. Transformational Leadership
A creation of a system-wide Fall Prevention Policy and staff education program
Standardized documentation in the EHR (EPIC) utilizing IHI Risk for Injury Assessment and MORSE FALL RISK Scale in adults, HUMPTY-DUMPTY Fall Risk Assessment in pediatrics
Review of NDNQI definition of falls and injury levels
Introduction of a Patient Fall Prevention Agreement
Institution of a weekly interdisciplinary fall prevention huddle meeting including the CNO, Director of Risk Management, Nursing Leadership/ Education, Directors of Physical Therapy and Pharmacy and front line staff

6. Replicability Joint Commission Cohort Unit Participation
20 to 30 falls per quarter were requested for data input utilizing the Joint Commission Data Collection Form
3 Medical – Surgical Units and the Acute Rehabilitation Services would participate
All nurse leaders would participate in project education and all nursing units would utilize the TST as the first line of review post fall, followed by a facility developed investigation tool

7. The Weekly Huddle Meeting
Utilizing the information from the TST and SCH Investigation Tool
Review all falls which have occurred in the prior week
Discuss pre and post fall interventions
Enhance Patient-Family education
Develop and implement an interdisciplinary Plan of care
All participants have an equal voice in the huddle discussion – how the fall occurred, how a future fall could be prevented

8. Additional Project Design Elements
Monthly cohort call led by the Joint Commission Project Leader
Six Sigma concepts used to track progress
Implementing change
Developing stake holder support
Utilizing a project contract
Falls definitions, severity level education
Data entry into TST
Implementing the Targeted Solution for contributing factors

13. TST Solution for Bathroom Assistance
Implement hourly rounding with proactive toileting for all patients
The 3 Ps (Pain, Potty, Position)
Implement scheduled toileting for all high risk patients
Set a time limit no more than 4 to 6 hrs go by before the patient is required to get up and use the bathroom
Ensure that a member of the staff remains with the patient at all times while toileting or showering
Make a commode available to high fall risk patients and store at bedside
Encourage patient to use the call light for assistance

14. Lessons Learned
TST and Six Sigma methodology could be applied to all clinical areas of the hospital
The approach provided consistency for all staff and unit managers
The commitment of the Senior Leadership Team with the CNO and Director of Risk Management attending the weekly falls huddle meeting demonstrates to all levels of staff that patient safety and fall prevention are a primary focus at St. Charles