Fall Prevention Deserves Your Attention: How Johnson City ... Fall...Using Lean Tools to Generate the Focus • Visual Management • Pareto Charts –“Let the data tell the story”

Fall Prevention Deserves Your Attention: How Johnson City Medical Center Reaches Root Cause

May 17, 2019

Jennifer Stuart, MBA, BSN, RN

Today’s Objectives

1. Facility Overview

2. Understand Reason for Action & Initial State Opportunities

3. Fall Drilldown Process

4. Fall Prevention Process Strategies

5. Case Study

May 17, 2019 Presentation Title2

Johnson City Medical Center



Licensed Beds: 501

Outpatient visits: 263,523

ED visits: 60,496

Average program LOS: 4.97

Average daily census: 328


• Level 1 Trauma Center

• Comprehensive Stroke Center

May 17, 2019

Reason for Action & Initial State Opportunities


We were experiencing issues relating to:1. High rate of falls2. Underutilization of tools3. Accountability4. Sustainment Opportunities 5. Lack of standardization


Initial State

• Unassisted Falls/ Assisted Falls FY Comparisons • Physiological related opportunities

• Medications /Altered mental status/Psych• Bathroom related opportunities

• Patients left alone• Failing to call for help

• Bed Alarm opportunities• Utilization • Notification of alarms to the staff

Target State


• Dismiss the myths• Reach the root cause by asking the right questions• Trend across the board for facility and units• Determine sustainable fall prevention tools• Gather a committee with various stakeholders• Process for drilling down and reporting• Standardization• Accountability• Create heightened awareness & culture shift


Using Lean Tools to Generate the Focus

• Visual Management• Pareto Charts – “Let the data tell the story”

• Majority of falls:• Tuesdays and Saturdays• 1p-7p• Involved seasoned staff

• Root Cause• Countermeasures• Standard Work

- Drilldown Tool for Nurse Managers- Weekly Fall Summary Tool - Monthly Fall Summary Recap Tool

Fall Drilldown Process – Weekly


• Reserved time• Leadership & frontline staff• Completed Drilldown Preparation• Present Fall• Discuss root cause• Committee reviews• Discuss trends• List Countermeasures and educational opportunities• Celebrate wins

Fall Prevention Process – Committee


• Review previous weeks falls totals and trends• Discuss opportunities • Review Vols for Falls prevention prior results• Discuss opportunities from the audit• Review prior weeks countermeasures• Discuss action items from the above reviews• End of month summary review• Algorithm usage/feedback

Case Study


What We LearnedProcess• Reviewed situation at hand• Manager consulted with fall

committee• Determined patient could benefit

from one of our fall risk tools (enclosure bed)

Challenge

• 84 year old male. Altered Mental Status, history offalls at home ,impulsive patient with dementia

• Night shift nurse “ camped” in front of room redirecting him• Day-shift nurse reported at boards ”This patient will fall”

• Needed better education on our tools available

• Appropriate escalation• Patient benefited, decreased

LOS, no sedation meds, patientcalmed

Case Study


What We LearnedProcess• Reviewed situation at hand• Manager consulted with fall

committee• Determined the manager

needed to have a conversationwith patient and family

Challenge

• 68 year male with cancer, just received the news from physician“There is nothing else we can do”

• Patient had fallen the previous night and was still refusing all fall precautions

• Ask better questions • Loss of Independence has to be

considered • Make the situation a “win-win”


Fall Prevention Strategies & Drilldown Discoveries

Gaps:• Ancillary departments had limited understanding of bed functionality• Beds not working properly• Varying levels of accountability

Solutions:• Educators to help provide education to ancillary departments• Nursing work order request education• Standardized Action Plans for consistent accountability


Fall Prevention Process – Vols for Falls• University of Tennessee Volunteers for Falls• 15 Fall Prevention Champions / Volunteers• Training• Auditing Tool • Real Time Feedback

Celebrations!


• 29% reduction in bathroom related falls

• 12% reduction in physiological related factors

• 30% of our units have been fall free since February

• 2 units have been fall free since September and November

• % of Improvement per Unit this FY:

• Projected to surpass the average assisted fall rate this FY

2200(13 falls to 9) 30.77%

2300(14 falls to 7) 50%

2700(10 falls to 2) 80%

4200(28 falls to 11) 60.71%

4300(27 falls to 9) 66.67%

6400(19 falls to 14) 26.32%

6500(7 falls to 3) 57.14%

Documents

Fall Prevention Deserves Your Attention: How Johnson City ... Fall...Using Lean Tools to Generate the Focus • Visual Management • Pareto Charts –“Let the data tell the story”