1. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Valley Park Manor (VPM) Red Deer, Ab Innisfail Continuing Care Innisfail, Ab AHS - DTHR

2. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Who We Are Innisfail Continuing Care - has 78 beds Contact Name: Norma Clynes (Innisfail) Email: nclynes@dthr.ab.ca Phone: 403-227-7390 Valley Park Manor - has 98 beds Contact Name: Sue Priest (VPM) Email: spriest@dthr.ab.ca Phone: 403-343-4722 Ext - 11

3. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Background Most frequently reported adverse event in DTHR Continuing Care Department Enrolled 2 teams from DTHR - –One rural continuing care site with dementia population (Innisfail) –One urban continuing care site Valley Park Manor (VPM) AIM To reduce the number of falls and severity of injury by 40% in Valley Park Manor and Innisfail Continuing Care Center by April 30, 2009

4. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Team Members Regional Planning Team- Partnership between Continuing Care & Quality Improvement & Patient Safety Membership:Cathy McDonald, Tracy Sommerfeld, Yvonne Hoppins, Norma Clynes, Deb Larratt, Sue Priest, Tracie Stewart - O’Brien, Fiona Brandt, Dianne Tartarnic, Sylvia Simmons Innisfail Site Team Norma Clynes, RN Deb Larratt, RN Valley Park Manor Sue Priest, RN Tracie Stewart- O’Brien, RN Fiona Brandt, OT Dianne Tartarnic,PT

5. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario PDSA-Innisfail Empower nursing staff to assess the needs of our residents and initiate use of the “Star” in preventing falls in those identified Poll interdisciplinary team members to see if they are aware of the “ Fall Logo” and it’s implications Monitor the effective placement of the “Star ” Engage families in the prevention of falls in our resident population using the “Star” Engage interdisciplinary staff in the prevention of falls amongst our residents, using the “Star”. Introduction of a “ Fall Logo” the “Star” to identify frequent fallers. Identification of “Frequent Fallers”-those residents who have fallen more than twice in one month.

6. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario PDSA-VPM Shift Huddle – Individual Resident Review “Lunch & Learn Education Sessions (flipchart) Post Fall Reminder Cards Hip Protector Assessment (OT & PT) Care Plan Notes (after chart review) Roll out (trial basis) interim care plan (# 4) as part of Admission Quick Screen Interim Care Plan – drafts # 2, # 3, and # 4 (after reviewing with Falls team)

7. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Challenges 1. Rate of Introducing 1 PDSA cycle per week - moved forward utilizing PDSA cycles on CoP 2. Staff Participation at Learning Opportunities - moved forward by increasing acknowledgement of front-line staff suggestions for improvement 3. Maintaining enthusiasm of fall collaborative - look at planning celebrations for small successes, posting data on progress for front-line staff, and encouraging front-line staff to make small changes.

8. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Lessons Learned What advice would you give to other teams? Information given to staff needs to be clear, concise and applicable for all members of a multidisciplinary team Remember to include all levels of staff including PCA’s Provide education to families of the residents

9. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Lessons Learned What are the Key Insights?: 1. Analyze the data in context and look at the reasons behind the data 2. Implementation of Fall Prevention Strategies needs to be balanced with personal independence 3. Assessment is only valuable when fall prevention and management interventions are put in place

10. National Collaborative on the Prevention of Falls in Long-Term Care Learning Session 3: February 9 & 10, 2009, Toronto, Ontario Next Steps Valley Park Manor Huddles Survey Front-line staff regarding education about falls Implement Fall Logo Implement Hip Protectors Innisfail Empower nursing staff to do fall assessments for putting residents on logo Complete environmental assessments

11. National Collaborative on the Prevention of Falls in Long-Term Care Results Learning Session 3: February 9 & 10, 2009, Toronto, Ontario

12. National Collaborative on the Prevention of Falls in Long-Term Care Results Learning Session 3: February 9 & 10, 2009, Toronto, Ontario

13. National Collaborative on the Prevention of Falls in Long-Term Care Results Learning Session 3: February 9 & 10, 2009, Toronto, Ontario

14. National Collaborative on the Prevention of Falls in Long-Term Care Results Learning Session 3: February 9 & 10, 2009, Toronto, Ontario

15. National Collaborative on the Prevention of Falls in Long-Term Care Results Learning Session 3: February 9 & 10, 2009, Toronto, Ontario

16. National Collaborative on the Prevention of Falls in Long-Term Care Results Learning Session 3: February 9 & 10, 2009, Toronto, Ontario