1. Falls Program Virtual Breakthrough Series 2: (BTS 2) Reducing Preventable Falls and Fall Related Injuries National Center for Patient Safety & VISN 8 Patient Safety Center of Inquiry Wednesdays, starting January 9, 2013 2-3p

2. Julia Neily, RN., M.S., M.P.H. Julia Neily, RN, MS, MPH, has worked for the VA in various nursing roles for 26 years. She is currently the Associate Director of the NCPS Field Office. She joined the VHA National Center for Patient Safety in 2002 and has focused on fall and fall related injury prevention and evaluation of patient safety efforts such as cogni­tive aids, Ensuring Correct Surgery and Medical Team Training. Julia has a BS in Nursing from the University of New Hampshire, a Master of Science from New Hampshire College and a Masters of Public Health from Dartmouth Medical School.

3. Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, Associate Director, VISN 8 Patient Safety Center of Inquiry, is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation. As Associate Chief of Nursing for Research, she is also a funded researcher with the Research Center of Excellence: Maximizing Rehabilitation Outcomes, jointly funding by HSR&D and RR&D. Her contributions to patient safety, nursing and rehabilitation are evident at a national level – with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.

4. BTS2 Program Goals: Improve your organization’s infrastructure and capacity to reduce fall-related injures. Enhance environmental safety. Mitigate or eliminate modifiable fall risk factors. Assure reliable handoff communication about patients’ fall and injury risk. Integrate patient (family) as a partner in their fall prevention program. Reduce rate of repeat falls. a Quantify impact of program changes. 4

5. Your Team Goals Each VAMC team will select the goals that you want to work on during this 6 month period. All teams do not need to work on all the goals, but rather are encouraged to select the goals that are congruent with you organization’s fall and injury prevention program needs. 5

6. Looking Ahead Ten Sessions of Learning and Sharing Jan 9 th : Improved Organizational Infrastructure and Capacity for Fall Prevention Programs Jan 23 rd : Ensuring a Safe Environment Feb 6 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 1 Feb 20 th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 2 Mar 6 th : Reduce Moderate to Serious Injuries for Vulnerable Populations Mar 20 th : Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries Apr 3 rd : Patients/Families as Full Partners in Fall Prevention Apr 17 th : Post Fall Management: Reducing Repeat Falls May 1 st : Fall Program Evaluation May 15 th : Sharing Program Successes 6

7. Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries Session 6

8. Objectives Decipher the purpose of handoff communication between and within departments. Distinguish handoff communication for guiding care of a "new" patient, a "known" patient, and a "known" patient with changes in status. Modify a handoff communication tool to "fit" your specialty population and setting. 8

9. But first… Let’s hear from you! Report on Session 5 Assignments: Who would like to share???? Test integration of injury risk assessment on admission for 3-5 patients Test use of the IHI Injury Matrix and ABCS tool on 3-5 patients Test redesign of visual cues 9

10. Handoff Communication A Review of Essentials Needed to Transform Healthcare

11. Background “Silence Kills” Report which revealed how improper communication and faulty collaboration leads to increased medical errors Mastering dialogue skills is crucial to safety in healthcare Maxfield et. Al (2005)

12. “Silence Kills” Seven categories of conversations to be mastered by healthcare professionals: Broken rulesMistakes Lack of support Incompetence Poor teamworkDisrespect Micromanagement Maxfield et. Al (2005)

13. “Silence Kills” National Focus Effective dialogue skills are learnable tools which need to be used in every handoff communication process. Maxfield et. Al (2005)

14. Joint Commission(TJC) 2010 Goals * Standardize critical content *Hardwire within your system *Allow opportunities to ask and respond to questions *Reinforce quality and measurement *Educate and coach. Joint Commission Center for Transforming Healthcare

15. The Veterans Administration Goals Quality of time versus quantity of time is essential for effective communication Avoid risk exposures: minimize interruptions and allow opportunity to ask questions Access historical data Department of Veterans Affairs

16. TJC Joint Commission Center for Transforming Healthcare Releases Tool to Tackle Miscommunication Among Caregivers http://www.centerfortransforminghealthcare.org /projects/detail.aspx?Project=1 http://www.centerfortransforminghealthcare.org /projects/detail.aspx?Project=1 http://www.centerfortransforminghealthcare.org /assets/4/6/CTH_Hand- off_commun_set_final_2010.pdf http://www.centerfortransforminghealthcare.org /assets/4/6/CTH_Hand- off_commun_set_final_2010.pdf

17. DoD and AHRQ TeamSTEPPS Fundamentals Course: Module 6: Communication http://www.ahrq.gov/professionals/education /curriculum- tools/teamstepps/instructor/fundamentals/m odule6/slcommunication.html http://www.ahrq.gov/professionals/education /curriculum- tools/teamstepps/instructor/fundamentals/m odule6/slcommunication.html

18. Systems Theory Not This!But This!

19. Literature Review Results Multiple studies which recommend the use of standardized tools for handoff process Limited studies which are supported by evidence based research

20. Widely Used Tools and Techniques Forms and checklists Audiotapes Verbal Report Electronic Report Runy, L 2008

21. I-SBAR Q I – Introduction S– Situation B—Background A—Assessment R—Recommendation Q—Questions and Answers Runy, L 2008

22. I PASS the BATON I – Introduction P– Patient A—Assessment S – Situation B - Background A— Action T— Timing O-Ownership N-Next

23. The Five P’s of Hand-off Patient - Identification Plan –Diagnosis and plan of care Purpose – Rationale for plan of care Problems - Specifics Precautions – Unusual circumstances Runy, L 2008

24. PACE P: Patient/Problem A: Assessment/Actions C: Continuing (treatments),Changes, Evaluation E: Evaluation

25. AORN Guidance / Recommendations: Hand-offs 1.Improved 2.Structured 3.Broadly interpreted to include pt care handoffs of all types 4.Include up-to-date Information 5.Should be Limited 6.Require a process of verification of received information 7.Opportunity to review relevance historical data 8.Clear transfer of responsibility 9.Clear language

26. Direct Observation Results All acute care units use electronic handoff tool which has TJC recommended elements. Elements of the tools vary according to the units’ needs. Tools are not consistently utilized during handoff report.

27. 27 Communication of Risk Handoff communication Hardwire content Hardwire process

28. Handoff Tool Let’s focus on Falls and Fall Injury Hand-off Please see additional handout

29. 29 Communication With Patients/Staff About Fall Reduction/Injury Prevention Label or signal patients assessed at risk of fall or injury Use signage/other visual indicators (bracelets, colored socks, special blankets, etc.) Ensure Safe Handoffs Verbalize and repeat-back risk of fall and risk of harm from fall at change of shift Verbalize and repeat-back risk of fall and risk of harm from fall between departments

30. 30 Communication With Patients/Staff about Fall Reduction/Injury Prevention Verify Understanding Use teach-back strategies to verify what patients and families understand and customize education about harm risk accordingly Learn from Failures and Transfer Learning Use unit-based post-fall team huddles to learn what happened and how to prevent injuries from future falls Discuss post-fall huddle findings at house-wide nurse manager meetings

31. 31 Visual Cues Re-evaluate use of visual cues – Patients – Staff Reinvent usage to identify vulnerable patients at risk for injury

32. Next Session Weds, April 3rd, 2013 2-3p ET Patients/Families as Full Partners in Fall Prevention 32