1. Intermountain-led CMS Hospital Engagement Network Falls and Immobility April 11, 2014 Affinity Call Marlyn Conti –Patient Safety Initiatives Manager and Eric Crawford, Data Manager Intermountain Quality and Patient Safety

2. Outline for Discussion Review of 2013 data through Q4 ‘High performers’ – Identify and ask what they are doing? Falls recommended metrics “Just-one-thing” – updated document 2014 plans for improvement: – Reach out to low performers to provide assistance – Continue Webinars for sharing

3. Overall Progress Through 2013

4. Intermountain HEN 2012-13 submitting Hospitals Falls with Injury

6. Intermountain HEN 2012-13 submitting Hospitals Inpatient Falls

8. HEN Falls Measures Metric specification resource manual http://www.henlearner.org/wp- content/uploads/2012/03/HEN_measure_Feb5.pdf http://www.henlearner.org/wp- content/uploads/2012/03/HEN_measure_Feb5.pdf Submission schedule: – May 20, 2014: for data through March 2014

9. HEN Falls Measures Inpatient Falls

10. HEN Falls Measures Falls with Injury

11. High Performing Hospital Highlight… Most Improvement Inpatient Falls Hospital Name PROVIDENCE SEASIDE HOSPITAL PARK CITY MEDICAL CENTER SUTTER TRACY COMMUNITY HOSPITAL CASSIA REGIONAL MEDICAL CENTER AMERICAN FORK HOSPITAL LOGAN REGIONAL HOSPITAL HEBER VALLEY MEDICAL CENTER PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL LINCOLN COUNTY MEDICAL CENTER SCOTT & WHITE HOSPITAL-ROUND ROCK

12. High Performing Hospital Highlight… Lowest Rate Inpatient Falls Hospital Name SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ GARFIELD MEMORIAL HOSPITAL PROVIDENCE SEASIDE HOSPITAL LOGAN REGIONAL HOSPITAL SUTTER TRACY COMMUNITY HOSPITAL PARK CITY MEDICAL CENTER OREM COMMUNITY HOSPITAL AMERICAN FORK HOSPITAL RIVERTON HOSPITAL CASSIA REGIONAL MEDICAL CENTER

13. High Performing Hospital Highlight… % Improvement Hospital Name UPPER CONNECTICUT VALLEY HOSPITAL FILLMORE COMMUNITY MEDICAL CENTER SUTTER TRACY COMMUNITY HOSPITAL PROVIDENCE MEDFORD MEDICAL CENTER VALLEY VIEW MEDICAL CENTER BAYLOR HEART AND VASCULAR HOSPITAL SUTTER LAKESIDE HOSPITAL SUTTER COAST HOSPITAL PROVIDENCE NEWBERG MEDICAL CENTER PROVIDENCE ST VINCENT MEDICAL CENTER Falls with Injury

14. High Performing Hospital Highlight… Lowest Rate Falls with Injury Hospital Name BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE PROVIDENCE MEDFORD MEDICAL CENTER BAYLOR MEDICAL CENTER AT CARROLLTON SUTTER TRACY COMMUNITY HOSPITAL SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ PROVIDENCE MILWAUKIE HOSPITAL PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER GARFIELD MEMORIAL HOSPITAL BAYLOR HEART AND VASCULAR HOSPITAL VALLEY VIEW MEDICAL CENTER

15. Just One Thing Matrix Recommendations Getting StartedWorking HarderAhead of the Curve Implement standard Assessment tools, protocols and prevention strategies (high level of evidence) Appoint “leads” to drive improvement & identify or champion teams that includes unit level nursing, quality, patient safety, physical therapy and pharmacy services. (high level of evidence) Implement decision algorithms and/or computerized decision support in the electronic medical record to target interventions based on patient specific risk factors

17. Inpatient Falls Savings (CPI+1)

18. Set Organizational priorityIdentify Risks and GapsDevelop Monitoring SystemsDesignate ChampionsIntegrated Nurse Charting and Care PlansRepeat Cycles of ‘Plan-Do-study-Act’ Getting Started and Keeping it going!

19. Fall Prevention Development Team Region Guidance (Fill in which team or committee has oversight) Facility Champion Team Nursing Safety Physical Therapy Education Pharmacy Fall Prevention Accountability and Communication Diagram NOTE: Could be Safety or Quality and Patient Safety Committee

20. Managing Improvement Development Identify best practice Blend guideline into work flow Design outcomes tracking Design decision support Staff and patient education Maintenance Keep Care process Current Clinical Learning Manager referral clinics Manage specialist care managers PDSA

21. 2014 plans for improvement Reach out to low performers to provide assistance. Collect and share best practices across our network hospitals & system in a single document