1. www.saferhealthcarenow.ca Rapid Fire Template for Teams Facilitator: Dania Versailles, MScN

2. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series 713 Montreal Road, Ottawa, ON. K1K 0T2 Number of patients/residents/clients: 300 beds 2,700 births a year 45,000 ER visits 1,500 employees and 300 physicians About us

3. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Objectives Based on your team charter: Reduce fall rate by 20% Reduce injury rate by 20% Increase compliance with administration of risk assessment on admission to 100% Increase compliance with documentation of a customized intervention plan to 100%

4. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Team members Roles and responsibilities of each member in your team Linda Lessard, Executive Partner, Director, Quality & Risk Management Dania Versailles, Team Leader, Clinical Nurse Specialist Madeleine Lauzon and Josée Berends, Clinical Educators Renée Morissette, Unit Team Leader Sylvie Denise Nault, Clinical Manager

5. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Review of changes that have been tested at your institution Changes implemented at the institution Successful/ Unsuccessful Facilitating factors (+) and obstacles (-) identified Use of mobile bed alarm  +Small successes; practical and quick instructions; direct support and availability in the units; management support; judicious use Major P&P revisions: prevention/post-fall intervention  +Support from the various partners/sectors involved (med., MD champion); networking 1.5- to 2-hour interactive training sessions/sector  +Commitment on the part of clinical educators and managers; close and regular communication -Volume of training sessions; lack of staff

6. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Review of changes that have been tested at your institution Changes implemented at the institution Successful/ Unsuccessful Facilitating factors (+) and obstacles (-) identified Creation of a reference binder (paper or electronic) Requested In progress (launch: mid- January 2011) Addition of revised P&P collection, toolkits, alternatives to restraints and post-fall decision trees; SBARR E-documentation project: Meditech pages revised for Morse Fall Scale, restraints,… (deployment: mid- January 2011) Subsidized short-term project; overseen by clinical informatics expert Business plan for the purchase of an integrated bed exit alarm In progress + Supported by 3 managers (technical resources, procurement and working group)

7. www.saferhealthcarenow.ca Falls Prevention Learning Series Review of changes that have been tested at your institution Changes implemented at the institution Successful/ Unsuccessful Facilitating factors (+) and obstacles (-) identified Incident/unit audits and communication of results to managers ------------------------ Monthly Meditech reports: falls and injuries/units  +Maintain communication with units; commits teams to adjust interventions with patients, health care team Monthly working group meetings  + Process catalyst

8. www.saferhealthcarenow.ca Falls Prevention Learning Series Review of changes that have been tested at your institution Changes implemented at the institution Successful/ Unsuccessful Facilitating factors (+) and obstacles (-) identified Monthly working group meetings  + Process catalyst Meeting with Équipe Qualité Médecine (Health Care Quality Team): -2012 action plan -November 2012 targeted -Posters for patient washrooms  + Mobilizes additional resources to create and sustain momentum;  sustainability

9. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Indicators Include all measurement indicators related to your objective. These may include indicators measuring your basic data as well as all subsequent data, depending on last submission. They may also include staff or patient feedback. Conduct audits and communicate results Meditech report (number of falls and injuries/unit/month) Feedback from members of the working group and staff (anecdotal) Number of initiatives implemented

10. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Lessons learned from work on sustainable and ongoing improvement in falls prevention during Action Periods What advice would you give to other teams? Importance of the PDSA cycles (document, assess and adjust planned activities) Keep key champions and target teams up-to-date on activities Use existing expectations (Accreditation Canada standards; the organization’s mission and strategic plan) as accountability elements Create an environment that supports the intended objectives and complementary activities What are your key ideas? Visibility, presence and engagement of Falls Program representatives Partnership and networking at multiple levels (internal via several sectors and external)

11. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series What were the obstacles? Outdated incident reports; workload distribution; working between meetings; irregular availability of support resources. What were the facilitating factors? Addition of resources (pharmacist); working group (monthly meetings); networking with internal and external partners; optimization of existing resources (LEAN Process) involvement of local level at national level; access to Meditech report system for audits/units; SHN and AIIAO support. What next step would you suggest? Supporting the addition of the program to the corporate QIP in order to reach other clinical and non-clinical sectors. Challenges to sustaining improvement in falls prevention

12. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Elements you will work on during Action Period #:  Potentially add the Falls Prevention Program to the hospital’s 2012- 2013 Corporate Plan  Integrate falls into daily operational processes:  Patient care rounding- Clinical managers (med.)  Environmental assessment – Team supervisors (med.)  Communication: caucuses, inter-professional meetings, unit meetings Next steps

13. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series  Inform physicians of changes as required  Create a post-fall analysis form (using a root cause analysis approach)  Establish a sub-group to develop a flyer for patients and families  Increase practices and resources that offer alternatives to restraints and revise the P&P with the RNAO’s BPG (to be released in January 2012)  Promote monthly “Non-Violent Crisis Intervention” training (CPI) Next steps (cont.)

14. www.saferhealthcarenow.ca Falls Prevention Pevention Learning Series Name: Dania Versailles, Clinical Nurse Specialist Email: dversailles@montfort.on.ca Phone: 613-746-4621, ext. 3706 Contact