1. Join the Falls Prevention Virtual Learning Collaborative Rapid Fire Team Presentation Team Call # 3 Name of Presenter: Sheryl L. Courtoreille, RN, BScN, Quality Improvement Coordinator

2. Name of Organization: Hay River Health & Social Services Authority Location of Facility: Hay River, NT. Number of Patients/Residents/Clients: Acute Care – 19 Extended Care – 10 Woodland Manor Long Term Care - 15 Who We Are

3. AIM Team Charter: Reduce incidence of falls (fall rate) by 40% from baseline by March 2011; Reduce injury from falls by 40% from baseline by March 2011; For 100% of inpatients to have a Falls Risk Assessment on Admission by March 2011; For 100% of inpatients who have fallen to have a Post Falls Prevention Injury Reduction Assessment completed by March 2011

4. Percentage of falls causing injuries – 41% Percentage of patients with completed falls risk assessment on admission – 30% Percentage of patients with completed falls risk assessment following a fall – 0% Percentage of “At Risk” patients with a documented falls prevention/injury reduction plan – 20% Baseline Data

5. Team Members Sue Cullen, CEO – Executive Sponsor Sheryl L. Courtoreille - Quality Improvement Coordinator (Lead Contact) Alex Simms – Occupational Therapist Jonathan Kennedy – Rehabilitation Aide Becky Boden, RN – Home Care Barb Holland, RN – Acute Care Evelyn Hempal, LPN – Long Term Care

6. Change Ideas Falls identifiers for “High Risk” clients to be: in the Care Plan; outside client room; at head of client bed; a yellow star label on spine of the client chart at the nursing station; and yellow arm bands (TBA).

7. Measures There is no direct measurement that is related to our AIM by doing this action We are not there yet but we will be there soon! Comments from clients: “pretty star” “how true!” Comments from Staff: no resistance to doing this action staff are recognizing the symbol and implementing identifiers on their own Measure: To have 100% of our “high risk” clients identified

8. Lessons Learned What advice would you give to other teams? In order to implement one change, you may need to do a lot of work and implement other changes to get to your original change; Ensure any changes/improvements to documentation is realistic; Don’t underestimate the education component; Start educating and informing staff of what you are trying to accomplish from the start of the project – may help with buy-in. Key Insights: Keep your Senior Management Team and Management Team abreast of what you are working on

9. What were some barriers? Staffs’ attitude towards changes and/or the idea of change; Staff lacking education in Falls Prevention Program and its importance; and Time needed to dedicate towards this project. How did you move forward? Had complete buy in from the Manager of Acute Care & CEO; Education came in the form of staff meetings with the Manager and one of our team members; Both were able to field questions and comments from staff; and Weekly meetings at a standard time to keep on track. Challenges

10. 1.Testing a Falls Prevention Injury Reduction Worksheet Combined the Admission Falls Assessment and Post Falls Assessment onto one sheet; Reformatted the Morse Falls Assessment so 5 assessments can be completed on 1 page; 2.Trialing “Bathroom” signs in the client’s rooms on the bathroom doors; 3.Defining a “Toileting Protocol”; 4.Transfer card implementation on Acute Care 5.Transfer belts in every client room 6.Allow time to pass to survey/audit changes and improvements 7.Educate, educate, educate! Next Steps

11. Name: Sheryl L. Courtoreille, RN, BScN., Quality Improvement Coordinator Email: sheryl_courtoreille@gov.nt.casheryl_courtoreille@gov.nt.ca Phone Number: (867)874-7168 Contact Information