1. Join the Falls Prevention Virtual Learning Collaborative Falls Virtual Learning Session # 4 & Closing Congress Team Rapid Fire Presentation Template MICs Group of Health Services-Anson General Hospital: Diane Martin, Tammy Brown

2. Anson General Hospital One of three partners in the MICs Group of Health Services Small Hospital in Northern Ontario Acute care: 19 beds Complex Continuing Care: 15 beds Who We Are

3. Team Members Team MemberRole Karen HillChief Nursing Officer- Executive sponsor Isabelle BoucherDirector of Quality, Risk and Patient Safety-team lead Patsy HuberDirector of Nursing Diane Martin, Cathy Bolton, Tammy Brown Nursing champions Joyce RickardPharmacy representative Erica BurtonDietician Craig OgdenPhysiotherapist

4. AIM Purpose of Falls Prevention Team To lead and coordinate team learning, process and care improvements; to ensure our targeted goals are achieved in falls and injury reduction and that we contribute as active participants in the SHN Falls Prevention VLC Scope & Boundaries 1.Patients at risk for Falls and Injury from Falls 2.Target patients from Acute Care at Anson General Hospital

5. AIM Improvement Aim  Reduce incidence of falls (fall rate) by 40% from baseline by March 2011  Reduce injury from falls by 40% from baseline by March 2011

6. Change Ideas List Changes you have tested during Falls VLC PDSA Cycles: Adoption of Falls Morse Scale tool on all new admissions Conduct post falls “huddle” using post falls checklist with all new falls Ensure high risk patients have documents fall prevention strategies on their care plans Ensure high risk patients have “apple” logo on spine of chart, at bedside and on white board to communicate risk to other staff Ensure high risk patients are in a “high-low” bed if available

7. Baseline Measures Indicator Baseline measure Target Fall rate per 1000 patient days12.44%Reduce by 40% Percentage of Falls Causing Injury54.5%Reduce by 40% Percentage of Patients with completed falls risk assessment on admission 0100% Percentage of Patients with completed falls risk assessment following a fall or significant change in medical status 0100% Percentage of “At Risk” Patients with a documented falls prevention/injury reduction plan 0100% Percentage of residents with restraints in place90% Maintain at baseline or below

8. Fall Rate per 1000 patient days

9. % Falls causing harm

10. Morse Falls Scale

11. Post Fall “Huddles” using Checklist

12. Post Falls Prevention VLC Indicator Baseline measure Target February 2010 Fall rate per 1000 patient days12.44% Reduce by 40% 4.88% Percentage of Falls Causing Injury54.5% Reduce by 40% 50% Percentage of patients with completed falls risk assessment on admission 0100%88% Percentage of patients with completed post falls checklist following a fall 0100% Percentage of “At Risk” Patients with a documented falls prevention/injury reduction plan 0100%

13. Lessons Learned List any “key” advice or insights you would like to share with other teams? Lessons Learned/Key Insights Team member roles and responsibilities need to be clear Team member engagement and commitment is key Education for all staff involved is necessary to ensure success Regular follow-up with progress and data collection Measure, measure, measure! Reward and recognize team member’s efforts

14. What are some things you will do to sustain the work on reducing falls and injury from falls and by what date? Next Steps Key Sustainability Steps/Plan:Target Dates Develop standard “falls prevention strategies” for patients at high risk for falls May 2011 Ensure high risk patients have documents fall prevention strategies on their care plans May 2011 Continue to conduct post falls “huddle” using post falls checklist with all new falls ongoing

15. Name: Isabelle Boucher Patsy Huber Email: isabelle.boucher@micsgroup.comisabelle.boucher@micsgroup.com patsy.huber@micsgroup.com Phone Number: (705) 273-2424 ext 1156 (705) 258-3911 ext 3301 Contact Information