1. Implementation Example Fall/Fall Risk Clinical Process Guideline Joint Provider/Surveyor Training September 15, 2009 Karen M. Kinyon, M.S., R.N., C.P.H.Q., N.H.A. 1

2. FOCUS-PDCA Find a process improvement opportunity Organize a team who understands the process Clarify the current knowledge of the process Understand process variation and capability Start the Plan-Do-Check-Act cycle 2

3. Find a process improvement opportunity High risk Problem prone Previous citations Rank order all clinical process guidelines based on previous quality findings Implementation plan for all guidelines 3

4. Organize an effort to work on improvement Team/Group Make-up Geriatric Resource Nurse Director of Nursing/Assistant DON Unit Managers Maintenance/Safety Champion Pharmacy Medical Director Staff Educator Social Work Admission Coordinator/MDS Coordinators Restorative Staff 4

5. Clarify the current knowledge of the process Clinical Process Guideline interpretation –Debra Ayres presentation –Clinical Process Guideline Team members –Review CPG Care Step Process/Expectations/Rationale Documentation Checklist: Audit tool Tables 1, 2, & 3 5

6. Understand process variation and capability Current practice compared to best practice Data collection Data analysis/display Identifying opportunities for improvement 6

7. Opportunities for Improvement Fall assessment History of previous falls Medication-recent change, interactions Appliances or devices-side rails Environmental factors-floor mats, transfer bars Physician participation in identification for medical cause of falls or medication related Physician identifies reasons for falls after interventions 7

8. Select a strategy for continued improvement Plan the improvement process Do the improvement Check the results and lessons learned Act by adopting, abandoning or accepting the change 8

9. Plan the improvement process Culture of safety Resident & staff understanding of a safe environment Positioning and bed safety Documentation Physician Pharmacist Nursing 9

10. Do the improvement Policy & procedure review/revisions Education of staff Education of residents/families Assessment & evaluation of current side rail use Assessment & evaluation of equipment Purchase of new equipment Revision of forms Development of new tools 10

11. Policy & Procedure Changes Resident Safety Report Investigation and Intervention Report Physical Safety: Sleeping Environment Physical Safety: Restraints Physical Safety Assessment & Admission Procedure Learning Tree 11

12. Forms/Brochure Resident Safety Report Investigation and Intervention Report Physical Safety Assessment Learning Tree Resident/family brochure: Restraint Use in the Long-Term Care Setting 12

13. Education Resident Council/Family Resident/Family Brochure Staff –RNs/LPNs/CNAs –Maintenance –Housekeeping –Activities –Therapy Education/Resource Manual Orientation Manual 13

14. Check the results/lessons learned Follow-up data collection Cost of change –Brochures –Positioning devices –Floor mats –Hand controls –Time Change is difficult 14

15. Act by adopting, abandoning or accepting the change On going training/education –Staff –Residents/families Future state = no side rails Reinforcement of change Can’t go back Celebrate success On going monitoring and data collection 15

16. Resources Process Guideline for Evaluation of Falls/Fall Risk http://www.michigan.gov/documents/mdch/bhs_CPG_Falls_Process_206279_7.pdf AMDA Clinical Process Guidelines, 2003. Centers for Medicare & Medicaid Services, State Operations Manual, Guidance to Surveyors for Long Term Care Facilities (2006) http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf. TMF Health Quality Institute, the Medicare Quality Improvement Organization of Texas-LTC Ombudsman Initiative: Restraint reduction Toolkit, 2007 http://nursinghomes.tmf.org/Restraints/RestraintToolkit/tabid/548/Default.aspx. MDCIS Guidelines for Use of Bed Rails in Long Term Care Facilities (March 1, 2001) http://www.michigan.gov/documents/cis_bhs_fhs_guidelines_bedrails_35726_7.pdf. 16

17. Questions? kkinyon@lakelandregional.org 1-269-473-3003 17