1. GHA Hospital Engagement Network HAC Learning Collaborative Falls April 18, 2012

2. Objectives ► Define evidence based practice elements of a comprehensive fall prevention program ► Discuss Lessons Learned from an incremental implementation strategy ► Describe the Test of Change process and how it can be used by your team.

3. DATA COLLECTION How to establish a plan

4. Data Collection Plan ► What process will you measure? –Percent of admissions with completed fall risk assessment within 24 hours of admission –Falls with injuries per 1000 patient days

5. Data Collection Plan ► What Aim does this process improvement opportunity align with?? –Safety –Effectiveness –Patient-centered Care –Timeliness –Efficiency –Equitableness

6. Data Collection Plan ► What population will you measure? –One unit –One diagnosis code –Entire facility

7. Data Collection Plan ► What data will be collected? –Utilize an evidence based Fall Risk Assessment within 24 hours of admission to ascertain fall risk for ALL admissions. This measure follows an “all-or-none” format. All components must be performed (or contraindications documented) for compliance to be recorded. –Patient Injury from Falls per 1,000 Patient Days―including minor, moderate, major, and death as defined by NQF: Minor: Injury that results in application of dressing, ice, cleaning of a wound, limb elevation, or topical medication Moderate: Injury that results in suturing, steri-strips, fracture, or splinting Major: Injury that results in surgery, casting, or traction Death: Death as a result of a fall)

8. Data Collection Plan ► Why is this process meaningful? –National Guideline –High volume –High Risk –Low Volume (problem prone) –Regulatory –Other

9. Data Collection Plan ► What source are you using to set your target? –Best Practice: specify guideline, competitor, internal comparison –Regulatory: TJC, CMS, other

10. Data Collection Plan ► Where will data be collected from? –Chart/Medical Record –Observation/Logs –Department or System Database –Other

11. Data Collection Plan ► When will data be collected? –Daily –Weekly –Monthly –Quarterly –Other

12. Data Collection Plan ► Who will collect the data? –Staff Leaders –Managers –Physicians –Other, please specify

13. Data Collection Plan ► What staff needs to be trained on how to collect the data? –List of specific titles –List of specific staff names

14. Data Collection Plan ► What method will be used to analyze and display the data? –Attribute Control Chart –Variable Control Chart –Other

15. Data Collection Plan ► What is the target for the measure? –0 events –100% compliance –other

16. EXAMPLES OF DATA DISPLAY

17. Injury Level after 24 Hours for All Falls 2008 - 2009

20. Next Steps ► May 16 meeting: Education & Training ► Progress to Date ► Results of Test of Change ► Areas of Success ► Areas of Improvement ► Lessons Learned

21. Questions? Kathy McGowan Georgia Hospital Association kmcgowan@gha.org 770-249-4519