1. A “Whole of Health System” Approach to Falls Prevention Moving Towards Zero Harm Ken Stewart Canterbury DHB Presentation 8 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC

3. How did we start?  Clinical Board leadership will make a difference to quality of care & patient safety across the entire system  Review current situation  Review the evidence for improvement strategies  Set clear goals and priorities for change as an action plan  Establish systems that allow and encourage best practice

4. enthusiasm

5. A big picture vision “ start at the end”

6. Getting Started

7. Problem  25% of ED falls presentations over 75 years from ARC  70% admitted to hospital Evidence  Vitamin D is a cost effective strategy to reduce falls in ARC (@ 50% 7 months ago) Solution “close the gap”  Set target of 75% of over 65’s in ARC on Vitamin D by 2013  Strategies – GP centred (currently at 63% cover- June 2012) Vitamin D in Aged Residential Care

8. Problem  Stable annual falls numbers last 3-4 years  37-40 serious or sentinel hospital events are falls-related each year  We spend over $600,000 treating these people every year Evidence (bundle!)  A multitude of guidelines & no single solution Solution -“close the gap”  System leadership alignment & communication (data & stories)  Nurses designing their own solutions based on evidence  A system-wide “take 5” strategy (5 “basics "every time)  Recognise Nurses as experts  Cross pollination, replication & high visibility Hospital Falls

9. Don’t give up!

10. Canterbury DHB reduces serious and sentinel falls events in hospitals by 50% in the first 12 months as part of a new system-wide falls initiative

11. Problem  Stable annual falls numbers last 3-4 years  37-40 SAC1/2 events were falls-related each year  We spent over $600,000 treating these people Solution  System leadership alignment & communication (data & stories)  Recognise Nurses as experts  Bundle the guidelines and adopt strategies in one part of system to influence change in another part Outcome  20 SAC1/2 events  Saved $400k in treatment  Saved 37 weeks of senior clinical staff time on avoiding 20 RCA’s Hospital Falls

12. Keep searching & learning from everyone!