1. Reducing Falls in Ward 5D and increasing days between falls
How do I get sustainability once the project is complete?
What’s next?

2. Using recognised SPSP guidelines
Aim: QI Reflections
Using recognised SPSP guidelines
One component of a larger bundle, 95% of all patients admitted to ward 5D will have received a copy of Positive Steps booklet and their relatives invited to attend a MDT education session
Ward staff open to idea and on board with Improvement methodology helped greatly
Focus on one ward initially then consider other areas
Time taken to progress, set up measures and find a good time to carry out tests – preparation time!

3. Project Measures
Process measures:
Number of nursing notes where it is recorded the provision of the Positive Steps booklet
Number of patients who have received the Positive Steps discussion and booklet
Number of carers/family invited to and attending educational sessions with staff
Collation of evaluation forms from educational sessions with staff/carers

4. Project Measures

5. Changes
Personalise the Positive Steps booklet for ward 5D
Introduce this into the admission check-in
Introduce a MDT Education session for carers/family of patients
Co-ordinating all relevant staff
Finding venue for education sessions and a time that suits everyone!!
Staff already busy with the day job………

6. PDSA Cycle Data/learning/adapting
Aim: Provide patient information on admission
Implement new process
Data/learning/adapting
Cycle 6: Test all nurses/patients
-1 week
Cycle 5: all nurses / patients on one day
Cycle 4: Test with 2nd nurse and two patients
Cycle 3: Test with 2nd nurse and one patient
Talk to slide – scaling up knowledge and engage other staff.
Hunch/Theory:
A patient leaflet given on admission will ensure relevant and helpful information on falls prevention is reliably and consistently given recorded
Cycle 2: Test with one nurse and two patients
Cycle 1: Test developed with one nurse and one patient

7. Prevention of Falls Driver Diagram
Outcome
Primary Drivers
Use of the Model for Improvement and local data to target and drive improvement
Define and collect process and outcomes data per measurement plan
Communicate process and compliance measures to clinical staff and management teams staff to ensure staff knowledge and understanding of the Model for Improvement and data for improvement
25% reduction in All Falls and a 20% reduction in Falls with Harm (as defined by SPSI) by end 2015.
The aim is to achieve a reduction in falls whilst promoting recovery, independence and rehabilitation.
Raise awareness of issues with clinical staff – ‘make the case’
Develop, test and implement: Falls Bundle for all Patient Safety Bundle for more vulnerable patients (and all patients in care of older people wards), Multi-disciplinary Assessment and Intervention Bundle for more vulnerable patients (and all patients in care of older people wards) and Post Falls Bundle
Improved clinical practice
Ensure patient and family centred care
Provide patient information on admission
Involve Patient/Family with Care Bundles and treatment process
Promote open communication among team and family
Optimise transitions to home or other facility
Patient and family involvement
Provide a culture & infrastructure to support safety and quality improvement. Ensure executive sponsorship and clinical leadership develop and implement a staff engagement strategy establish a multi-disciplinary team to lead the work, including QI support. Raise awareness of falls bundles across the organisation optimise the physical environment.
Infrastructure & Culture

8. My Improvement Journey so far…
Best Things
Hearing patients experiences and their own journey
Being made welcome onto the ward
Most Challenging
Juggling ward routines with additional activity – shifts and consistency of staff availability
Questions
How do I get sustainability?
Then what’s next?