1. Intermountain-led CMS Hospital Engagement Network Falls Prevention October 10, 2014 Affinity Call Marlyn Conti, BSN, MM, CPHQ Patient Safety Initiatives Manager Intermountain Healthcare Quality and Patient Safety Jason Scott, MPH, MPP Carlos Barbagelata, MS

2. Outline for Discussion Review of data through Q2 2014 ‘High performers’ – Identify and ask what they are doing? Falls recommended metrics “Just-one-thing” – updated document 2014/15 plans Reach out to low performers to provide assistance Continue Webinars for sharing? 2015?

3. Overall Progress Through Q1 2014

4. Overall Progress Through Q2 2014

5. Intermountain HEN 2012- Q2 2014 submitting Inpatient Falls with Injury High Performing Benchmark: 0.50

6. Intermountain HEN 2012- Q1 2014 submitting Inpatient Falls with Injury

7. Intermountain HEN 2012-Q1 2014 submitting Hospitals Inpatient Falls High Performing Benchmark: 2.15

8. Intermountain HEN 2012-13 submitting Hospitals Inpatient Falls

9. HEN Falls Measures Metric specification resource manual http://www.henlearner.org/wp- content/uploads/2012/03/HEN_measure_Feb5.pdf http://www.henlearner.org/wp- content/uploads/2012/03/HEN_measure_Feb5.pdf Submission schedule: Nov 20, 2014: for data through August 2014

10. HEN Falls Measures Inpatient Falls

11. HEN Falls Measures Falls with Injury

12. High Performing Hospital Highlight… Most Improvement Inpatient Falls Most Improvement BAYLOR ALL SAINTS MEDICAL CENTER AT FW HEBER VALLEY MEDICAL CENTER DELTA COMMUNITY MEDICAL CENTER AMERICAN FORK HOSPITAL BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE SUTTER COAST HOSPITAL CASSIA REGIONAL MEDICAL CENTER EDEN MEDICAL CENTER ESPANOLA HOSPITAL PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL Lowest Rates BAYLOR ALL SAINTS MEDICAL CENTER AT FW MENLO PARK SURGICAL HOSPITAL OREM COMMUNITY HOSPITAL HEBER VALLEY MEDICAL CENTER DELTA COMMUNITY MEDICAL CENTER GARFIELD MEMORIAL HOSPITAL BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ AMERICAN FORK HOSPITAL BAYLOR MEDICAL CENTER AT WAXAHACHIE

13. High Performing Hospital Highlight… Most Improvement Inpatient Falls with Injury Most Improvement BAYLOR HEART AND VASCULAR HOSPITAL BAYLOR ALL SAINTS MEDICAL CENTER AT FW DELTA COMMUNITY MEDICAL CENTER AMERICAN FORK HOSPITAL PROVIDENCE NEWBERG MEDICAL CENTER PROVIDENCE MEDFORD MEDICAL CENTER SUTTER COAST HOSPITAL UPPER CONNECTICUT VALLEY HOSPITAL SUTTER SOLANO MEDICAL CENTER SUTTER DAVIS HOSPITAL Lowest Rates BAYLOR ALL SAINTS MEDICAL CENTER AT FW BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE THE HEART HOSPITAL BAYLOR PLANO PROVIDENCE MEDFORD MEDICAL CENTER BAYLOR MEDICAL CENTER AT CARROLLTON SUTTER SOLANO MEDICAL CENTER BAYLOR MEDICAL CENTER AT WAXAHACHIE SUTTER DAVIS HOSPITAL SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ AMERICAN FORK HOSPITAL

14. Just One Thing Matrix Recommendations Getting StartedWorking HarderAhead of the Curve Implement standard Assessment tools, protocols and prevention strategies (high level of evidence) Appoint “leads” to drive improvement & identify or champion teams that includes unit level nursing, quality, patient safety, physical therapy and pharmacy services. (high level of evidence) Implement decision algorithms and/or computerized decision support in the electronic medical record to target interventions based on patient specific risk factors

15. Set Organizational priorityIdentify Risks and GapsDevelop Monitoring SystemsDesignate ChampionsIntegrated Nurse Charting and Care PlansRepeat Cycles of ‘Plan-Do-study-Act’ Getting Started and Keeping it going!

16. Falls Bundle & Falls Survey Report

17. Falls Bundle Measurement Inpatient falls rate Falls/Patient Days Fall-related injuries/patient days CMS Hospital Acquired Conditions (HAC) rates Assisted vs unassisted falls Assessment & Reassessment Standard risk assessment tool (standardized across all care settings) Policy for timing of assessment Reassess when condition changes and after procedures

18. Falls Bundle Interventions Signage Door frame magnet/Door signs Patient/Family Education Standard FAQ sheet Room environment Bed low, room free of clutter, side rails up, bed alarms on Visibility Made reminders larger and brighter (yellow blankets, slippers, etc) Fall prevention protocol recorded in medical record Hourly rounding made part of falls protocol Safe Patient Handling (no lift) policy

19. Falls Bundle Patient Family Education Standardized education content Available as applicable just-in-time), online, etc Validation that learning has occurred such as a teach-back concept or skills pass-off. Staff Education & Learning Standardized education contend on hire Annual skills fairs Annual assigned learning modules Leadership/Structure Fall prevention team Integration with quality and patient safety plan and structure Unit level & hospital level Fall Prevention champions Post fall huddles and fall evaluation/questionnaire

20. Falls Bundle Equipment Beds Standard models where possible, reduces learning needs and maintenance issues Bed Alarms Integrated with nurse call systems when possible Lifting Equipment Available and in use (portable, overhead, and transfer such as gait belts, slider sheets/boards, etc.) Nurse Call System Integrated with beds and/or communication devices Environmental Safety Electrical outlets, lips on doorways

21. Falls Survey Results

22. 1. What facility are you from? 17 Facilities Responding Baylor Baylor Scott & White Hillcrest Medical Center - Waco Texas Dr. Dan C. Trigg Memorial Hospital Intermountain Medical Center Intermountain SWR Mayo Clinic Health System - Franciscan Healthcare Mayo Clinic Health System - Northland McKay Dee Presbyterian Ph-Main campus Primary Children's Hospital Providence St. VIncent Medical Center Regions Hospital, St. Paul, Minnesota Riverton Sanpete Valley Hospital Sutter Medical Center Santa Rosa, Ca Upper Connecticut Valley Hospital VVMC

23. 2. What is your role at your facility? AnswerResponse% Quality1144% Nursing1040% Other (Specify)416% Education00% Total25100% Other (Specify) Patient Safety Nursing Quality Patient Safety Nurse Manager

24. 3. What is the size of your facility? AnswerResponse% >200 people1973% 100 - 200 people415% 20 - 49 people312% 50 - 99 people00% Total26100% 4. Does your facility have a leadership-appointed fall prevention team assigned to work on fall prevention? AnswerResponse% Yes2388% No312% Total26100%

25. 4a. Is your fall prevention team multidisciplinary? (if yes, which disciplines are included?) AnswerResponse% Yes1986% No314% Total22100% Yes PT, Pharmacy, Risk, Dietary nursing, PT/OT, patient safety, facility safety and security, occupational health, physicians nursing, PT/OT, Security, Education, IT, Radiology, Quality Rehab, Transportation, Environmental Services, Lab, Nutrition Safety officer, lift team, Nursing (bedside, managers and directors), Risk and quality members Nursing (Med/Surg, OR, Mental Health, ICU, Acute Rehab, ED), Pharmacy, Physical Therapy, Nursing Education, Patient Safety, nursing, PT, OT, pharmacy, resp, lab, physicans, Social work, and case management. Managemet, OT/PT, Pharmacy, Quality, Nursing PT, Pharmacy, employee health Nursing, PT, Imaging, Patient Relations, Security, Quality, Risk Nursing, Radiology, Lab, all outpatient areas, Risk, Quality,

26. 4b. How frequently does your fall prevention team meet? (Check all that apply) AnswerResponse% Once a Month1565% 2-3 Times a Month00% Once a Week00% Other (e.g as-needed, etc.) 835% Other (e.g as-needed, etc.) Quarterly or more often as needed Have been once a month, now quarterly As-needed

27. 5. What standard risk assessment tool do you use? AnswerResponse% Other1148% Morse730% Hendrick417% Hybrid Tool29% Schmidt00% Other Developed own EPIC Moving to Morse soon Combination of morse and our tool Johns Hopkins Unsure Tandem Intermountain tool Humpty-Dumpty in near future

28. 6. Do you have bed exit alarms integrated with the nurse'scall system? AnswerResponse% Yes1869% No831% Total26100% 7. Do you use a patient contract for falls risks? AnswerResponse% No2492% Yes28% Total26100%

29. 8. What tools do you use to educate patients/families about fall prevention? (check all that apply) AnswerResponse% Fact Sheets1875% Online materials729% Other (specify)1250% Other (specify) Teaching by RN's and staff Verbal teaching regarding falls risk and interventions Verbal Education Teaching sheets Handout and verbal communication Whiteboards reminders, Discussion Face-to-face discussion Communication board, unit orientation, rounding In-room white boards

30. 9. What tools do you use to educate staff about fall prevention? (check all that apply) AnswerResponse% Posters1976% Fact Sheets1664% Assigned Computer-Based Training2392% Other1144% Other Annual fall prevention workshop and online training Staff meetings Unit Based Falls Champion Shared Decision Making Staff meeting, post fall assessments, and review of cases Orientation checklists Post falls huddle, annual skills day Huddles, staff meetings, Metric Boards 1:1, unit fall champions, newsletter articles

31. 10. With what frequency do you assign staff education? (Check all that apply). AnswerResponse% Annual2388% As-Needed1662% On Hire1142% Other (Specify)312% Every Other Year00% 11. Do you provide patient fall incidentevent reports for use by hospital staff managers and teams? (If yes, please describe how reports are distributed or made available). AnswerResponse% Yes2388% No312% Total26100%

32. 11. Do you provide patient fall incident event reports for use by hospital staff managers and teams? (If yes, please describe how reports are distributed or made available). Other Via email to unit managers and designated staff leaders Available via reporting system Staff meetings, Electronic Event System Information is discussed at meetings with leaders and at staff meetings. Patient information and outcomes are shared but never posted. Data about falls is posted in the nursing units Reports are viewed and managed at a local level of the location of the fall. Falls Prevention team analyzes the data from the reports to identify house-wide trends. Event reports are filled out online and can be accessed by managers and quality improvement staff. Post- fall assessment are filled out and scanned to management, and falls committee representative Fall with injury reports are sent to unit managers post-fall debrief. Statistic reports are available via STATIT and a monthly report is shared to nursing managers at the monthly fall team meeting. Data from risk, collected by Quality, shared with staff, managers, leadership, governing board, and medical staff. Shared with managers who, in turn, educate and follow up with staff. Stats are shared with managers and staff. Fall reports for hospital and per units with monthly rate and rolling 6 month rate, also have fall prevention bundle audit data

33. 12. What is the most successful approach that you feel has contributed to reducing patient falls? Text Response Getting staff involved in assessing their own unit readiness to prevent falls. Making it a goal with incentives for completion. Telling stories about falls and near misses. Integrating fall prevention with safe patient handling. The visuals applied: This helps all staff identify which patients are high risk falls.(i.e) Gait belts hanging on door frame, red booties on falls risk patients,bedside reporting also helps remind patient and family members. Proper equipment, staff training, frequent reminder of importance, keeping it in the forefront at all times Change in culture - falls are not expected or a natual part of being hospitalized. Constant vigilance; staff accountability; manager engagement; unit-based champions; current data - metrics; Falls prevalence monthly, multildisciplinary approach and the increase in lift equipment and the use of a lift team. Staff awareness, daily huddle focus, and education Root Cause and Common Cause Analysis with Direct Feedback to Staff, Units, Ministries. Assessment tools that identify high risk patients, bed alarms, chair alarms, pt's are designated as a falls risk on patient census board, and fall magnets are placed outside doors. If a fall occurs we do post fall assessment and identify any contributing factors and or trends. Partnering with family/caregivers to team up to prevent falls. Making our team multidisciplinary, Fall contracts and hourly rounding addressing the 4 Ps Bed alarms connected to call system. awareness when falls occur what the reasons were reported to quality and patient safety committee. clinical ladder RN project for 2014 Currently piloting. No One Walks Alone program. We got our infromation from Kaiser San Diego. Pilot has just begun but has provided data that it may have a profound impact on our overall fall rate. Repeat falls reduced by standardizing the interventions once a patient fell and the use of alarms to prevent falls Required monthly audits done by each unit to ensure our falls prevention strategies are in place - magnets, stickers, gait belts, bed alarms, white boards, risk scores etc.

34. 13. To help us measure progress, please indicate your facility's program status since starting the HEN collaboration to reduce patient falls. A. "Getting Started": This level consists of implementing standard assessment tools, protocols and prevention strategies. B. "Working Harder": This level focuses on appointing "leads" to drive improvement and identify SWOT (or champion) teams that includes unit nurse. C. "Ahead of the Curve": This level focuses on implementing decision algorithms and/or computerized decision support in the EMR based on patient risk factors. What level do you feel your facility is at? AnswerResponse% Getting Started624% Working Harder1040% Ahead of the Curve936% Total25100%

35. 14. What barriers are you experiencing that are preventing you fromachieving your goals to reduce patient falls? Fall Prevention Barriers Enough bandwidth to keep up the focus. Time, consensus, conflicting priorities. Staff shortages. Patient acuity and volume. Buy in from unit managers and their staff High falls risk patients inability to remember they can not ambulate on there own."Patients cognitive level" Equipment issues, Many changes in workflow. Accountability issues. Multiple competing priorities that seem to switch the focus away from fall prevention; increasing Nurse Patient Ratios; staff turnover; Consistency in standard implementation -- variability amoung staff performance. Dementia patients who can not find SNF placement related to behavior--longer stays increase risk Staff engagement with the process. Hospital does not bed alarms on every bed and alarms are not routed to the nurse call system. Staff perception with nursing ratios increasing is the hardest thing. There are certain things that are outside of our control no matter how hard we work and no matter what interventions we put into place! It's very frustrating.. Have been able to work through barriers. Zero falls with moderate or severe injury in 698 days (since we began monitoring in Nov 2012. 100% of staff staying in bathroom with patient and not "turning to get something outside of the bathroom" Consistently remembering bed alarms In children, falls don't usually cause expensive harm or injury as in adults, so leadership often overlooks the importance of fall prevention as a proactive process.

36. Final Thoughts

37. 1. What changes have you made since joining the HEN to reduce falls? 2. What have you done to recognize achievements in fall reduction?