1. Intermountain-led CMS Hospital Engagement Network Fall Prevention October 11, 2013 Affinity Call Marlyn Conti, RN, BSN, MM, CPHQ Quality and Patient Safety Initiatives Manager Intermountain Fall Prevention Team Leader

2. Webinar guidelines Put phone on ‘mute’ versus ‘hold’ when you are not speaking Right click on your phone number on the participants list to add your name (this helps us know who is attending)

3. Outline for Discussion Review recommendations Getting your feedback Discussion Review current data

4. Recommendations Getting Started Implement standard Assessment tools, protocols and prevention strategies Working Harder Appoint “leads” to drive improvement & identify SWAT (or champion) teams that includes unit nurse Ahead of the Curve Implement decision algorithms and/or computerized decision support in the electronic medical record based on patient risk factors

5. Your Feedback What stage is your organization at; ‘getting started’, ‘Working Harder’ or ‘Ahead of the Curve’? What actions did you take in ‘getting started’? What actions did you take in ‘working harder’ stage? What actions did you take in ‘ahead of the ‘ahead of the curve’ stage?

6. Intermountain HEN Q1 2012- Q2 2013 submitting Hospitals

7. Intermountain HEN Hospitals submitting Inpatient Falls

8. HEN Falls Measures Metric specification resource manual http://www.henlearner.org/wp-content/uploads/2012/03/HEN- measure-Jul12.pdf Submission schedule: – November 20, 2013: for data through September 2013

9. Intermountain HEN Q1 2012- Q2 2013 Falls with Injury Rates Our HEN rate is around 0.44 – EXCEEDING EXPECTATIONS! The national high performing benchmark is 0.5.

10. Intermountain HEN Hospitals submitting Falls With Injury

11. Intermountain HEN Q1 2012- Q2 2013 submitting Hospitals

12. Intermountain HEN Hospitals submitting Assisted Falls

13. Poll Results from July HEN Affinity Call for Patient Falls Have you standardized timing and frequency of fall risk assessments? Yes79%No7% If yes, do you measure it? Yes36%No43%

14. Poll Results from July HEN Affinity Call for Patient Falls Do you have standard interventions in place? Yes79%No7% Do you have a policy or procedure in place? Yes71%No14%N/A0%

15. Poll Results from July HEN Affinity Call for Patient Falls Do you have standard patient/family teaching tools in use? Yes69%No23% Do you have standard tools? Yes69%No23% N/A0%

16. Poll Results from July HEN Affinity Call for Patient Falls How do you know if it is done? – Documentation in the patient record – We are currently working on this initiative. We are developing a field in Epic to document. – Document on chart, do not measure routinely – Do not measure – Not measured but included in admission information – EMR audits- not routinely audited- mostly audit chart if fall occurs – We do not measure this – I do not believe it is measured. It is supposed to be part of the orientation to the unit and then frequent reminders during hourly rounding. – Still working on measuring – We don't have a consistent measurement – See in documentation of notes of EHR, but really hard to measure if not really doing this but just hitting

17. Poll Results from July HEN Affinity Call for Patient Falls Do you have required care team education in place? Yes62%No23% If yes, how often is the education required? – Annual – Annually – Yearly – Every 2 years – Only on orientation to the units – At hire...orientation only. – At orientation and yearly – Not required – In orientation, annually and with any change in policy/ or fall prevention program update

18. Poll Results from July HEN Affinity Call for Patient Falls Do you have a safe patient handling policy? Yes77%No15% Do you have safe patient handling equipment, i.e., lifts, in use on all inpatient units? Yes85%No8%

19. Next Actions – Poll questions What are your greatest challenges? What will you do to holds the gains? What do you need the HEN to do?

20. Next Affinity Call? January 2014??