1. Illinois Division of Mental Health Quality & Safety Improvement Initiative Charter Team Topic: Fall Risk Assessment Hospital: CMHC QCSI III Charter Teams Report Out Meeting June 24, 2013 – Springfield, IL DRAFT: For Review and Discussion1

2. Charter Team Members Jennifer Klingeman RN, DON, Team Leader Leah Hammel RN, MSN, ADON Dr. Ahmed Tariq Tammy Crawford, RN, Clinical Nurse Manager Christie Modglin RN, Clinical Nurse Manager Tammi Craig RN, Clinical Nurse Manager Holly Hawkins RN, Clinical Nurse Manager Stephanie Kisro, RN Van Mueller, STA DRAFT: For Review and Discussion2

3. Topic: Fall Risk Assessment Overview of Deliverables A.Design and develop processes for the evaluation & management of Falls through screening, appropriate assessment & effective intervention. B.Design & develop training to ensure staff knowledge & appropriate/effective application of the risk assessment processes. C.Identify a core set of activities that indicate appropriate use of the risk assessment processes & provide recommendations for related evaluation measures & monitoring. DRAFT: For Review and Discussion3

4. QCSI Charter Team Work Process Literature Review – Fall Risk Assessment – Validated Risk Assessment Tools (EFRAT) Review of other facility Fall Risk Assessment Tools – Elgin, Madden, Choate, McFarland Face to Face Meetings Risk Assessment Tool Revision/Development – Evidence Based Practice – Best Practices DRAFT: For Review and Discussion4

5. Difficulties/Barriers Scheduling Meetings to accommodate all members – Email – Individual meetings – Minutes from meetings DRAFT: For Review and Discussion5

6. Deliverables/Work Products Instructor led training program – Discussion Goals, Objectives, revised policy / tool – Group activity Scenario – Question & Answer – Post test DRAFT: For Review and Discussion6

7. Deliverables/Work Products (cont.) Evaluation – Plan of care interventions treatment plan – Fall Rate data # falls / resident days x 1000

8. Outstanding Questions/Issues Will the revised tool have an impact on facility fall rates? What will the comparison of the annual fall rates pre and post implementation of the revised tool reveal? Will the revised tool improve the process of implementing interventions into the treatment plan? Further research, perhaps a longitudinal study, is needed to draw conclusions whether the Fall Risk Assessment Tool itself is responsible for early identification of fall risks. DRAFT: For Review and Discussion8

9. Lessons Learned/Recommendations Great way to implement Evidenced Based Practice. Great way to promote teamwork. Great way to promote ownership. Allow longer period of time to complete project. DRAFT: For Review and Discussion9

10. References Edmonson, D., Robinson, S., & Hughes, L. (2011). Development of the Edmonson Psychiatric Fall Risk Assessment Tool. Journal of Psychosocial Nursing, 49(2), 29-36. doi:10.3928/02793695-2010/202-03 Fineout-Overholt, E., Melnyk, B. M., & Schultz, A. (2005). Transforming healthcare from the inside out: Advancing evidence-based practice in the 21st century. Journal of Professional Nursing, 21(6), 335-344. doi:10.106/j.profnurs.2005.10.005 Harrington, L., Luquire, R., Vish, N., Winter, M., Wilder, C., Houser, B.,...Qin, H. (2010). Meta-analysis of fall-risk tools in hospitalized adults. Journal of Nursing Administration, 40(11), 483-488. doi:10.1097/NNA.0b013e3181f88fbd

11. References (cont) Ireland, S., Lazar, T., Mavrak, C., Morgan, B., Pizzacalla, A., Reis, C., & Fram, N. (2010). Designing a falls prevention strategy that works. Journal of Nursing Care Quality, 25(3), 198-207. Johnson, J. E., Veneziano, T., Green, J., Howarth, E., Malast, T., Mastro, K.,...Smith, A. (2011). Breaking the fall. Journal of Nursing Administration, 41(12), 538-545. doi:10.1097/NNA.0b013e3182378d53 Knight, M., & Coakley, C. (2010). Fall risk in patients with acute psychosis. Journal of Nursing Care Quality, 25(3), 208-215.

12. References (cont) Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. (2010). The seven steps of evidence- based practice. American Journal of Nursing, 110(1), 51-53. Poe, S. S., Cvach, M. M., Gartrell, D. G., Radzik, B. R., & Joy, T. L. (2005). An evidence-based approach to fall risk assessment prevention, and management. Lessons learned. Journal of Nursing Care Quality, 20(2), 107-116. Roussel, L., & Swansburg, R. C. (Eds.). (2009). Management and leadership for nurse administrators (5th ed.). Sudbury, MA: Jones and Bartlett.

13. References (cont) The Joint Commission. (2011). 2011-2012 National patient safety goals (Standards). Retrieved from The Joint Commission: http://www.jointcommission.org/assets/1/18/2011- 2012_NPSG_Presentation_FINAL_8-4-11.pdf