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HRET HIIN Falls Event
Teach-Back for Falls Safety:
Beyond Checking the BoxMay 11, 2017
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Welcome and Introductions
Erin Craig, MPA
Senior Program Manager | HRET
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HRET HIIN Rural/CAH Event: Get on Track with Antibiotic Stewardship Monday, May 15, 2017, 1-2pm CT
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HRET HIIN Leadership Event: Huddle Up for SafetyThursday, May 18, 2017 11am – 12pm CT
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HRET HIIN PFE Fundamentals: Session #3: Preparing Patient and Family Advisors: Orientation?
Tuesday, May 23, 2017 11am – 12pm CTRegister
View all upcoming events
Upcoming Events
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Join the Hospital-Wide (Falls) LISTSERV® and enjoy benefits such as:
• Sharing of HRET HIIN resources• Peer-to-Peer sharing of best practices and networking• Learnings from subject matter experts• Sharing of publically available resources
Sign up today!
Join the Falls LISTSERV®
2017 Falls with Injury Change Package
Falls with Injury Change Package Falls Top Ten Checklist
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Agenda for Today
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1:00-1:05 p.m. Welcome and Introductions
Erin Craig, MPA
Senior Program Manager, HRET
1:05-1:10 p.m. HIIN Falls Data Resources and Update
Preview HIIN Falls data collection fact sheet and hear an overview of
our data submission progress.
Mariana Lesher, MS
Data Analyst, HRET
1:10-1:30 p.m. Honoring the Patient’s Autonomy and Independence
Explore the nurse’s ethical role in supporting a patient’s informed
decision making and independence while in the hospital. Move beyond
labeling patients as “non-compliant” to discover techniques that
engage patients in safety by linking consequences to their choices.
Patricia Quigley, PhD,
ARNP,CRRN, FAANP
Nurse Consultant
1:30 – 1:45 p.m. Hospital Story
Learn from a HIIN fellow how patient and family engagement has been
adopted as a successful strategy to reduce injurious falls.
Ruth Zimmerman
Summit Health, AZ
1:45 – 1:55 p.m. How to Make Teach-Back Stick
How-to tips and tools for spreading the practice of teach-back to
nursing staff.
Jackie Conrad, RN, MBA, RCC
Betsy Lee, RN, MSPH
Improvement Advisors, Cynosure
1:55-2:00 p.m. Bring it Home
Erin Craig, MPA
Senior Program Manager, HRET
Who is in the Room?
• What department do you represent?
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Nursing
Rehab
Pharmacy
Medical Staff
Quality
Administration
Other
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Teach Back Uptake
• How far along is your organization in utilizing teach back to solidify patient and family engagement?
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Not thinking about it
Thinking about it
Started planning
Have implemented on a small scale
Have implemented fully and maintaining
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Heads Up!Start thinking…what will be your next move?
• What are some practical applications of today’s presentation that you can implement in your acute setting to reduce falls among your patients?
• Be ready to chat in your response after the hospital story
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Fall Data Resources and Update
Mariana Lesher, MS
Data Director| HRET
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Data Resources
Falls Fact Sheet
EOM Encyclopedia of Measures
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Falls Data Update
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October through March hovering above the HIIN baseline.Data submission is below 70% of expected for the entire period.
For hospitals with baseline and some 4Q 2016 data (n=1,057)
55% meeting program goals or maintaining a zero rate
Redesigning Patient Education: Patient Engagement and
Autonomy
Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANPNurse ConsultantRetired Associate Director, VISN 8 Patient Safety CenterRetired Associate Chief for Nursing Service/Research
E-Mail: [email protected]
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Objectives
• Consider patient / resident autonomy as primary factor
• Redesign patient/resident education to fully engage them as full partners in care
• Apply adult principles to two essential patient education strategies (Teach Back, Ask Me 3)
• Expand patient education resources
Questions to ponder…....
• How do you know your patient education program is effective?
• Can you confirm that patients learned what you taught them?
• How to implement patient education for those with cognitive impairment?
Empowering Patients and Families Through Learning
My Focus: Patient Falls
Partnership
• Patients– Need support and education to make good choices
– Benefit from easy to use directives
– Need to be accountable
– Need practical examples to put principles into place
• Family– Partners in Care – Advocates, Information
Gatherers
– Messengers
– Provide ongoing assessment in the home
– Teach clinicians about their safe practices
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Changing Your Conversation with Patients
• Do you label Patients / Caregivers: Non-Compliant?
• What does Non-Compliant Mean to You?
• How do you measure your effectiveness?
• How do you evaluate effectiveness of your teaching?
Autonomy• What does this mean to you?
• What happens after a fall?
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Patient Education is Not One Way Communication
• Think Systems Theory
• Teaching Individualized Fall Risk Factors
• A Simple Example: Blood Thinners – What to do if you fall?
Blood Thinners: Risk Factors and What to do when you fall
Program Effectiveness AND Implementation Effectiveness
Program Effectiveness
Implementation Effectiveness Outcome
+ program, - implementation = inconsistent, unsustainable, or poor outcomes
- program, + implementation = poor outcomes
“Teach Back”
• “Teach Back” Testing: what are the trends in patients’ difficulty to understand what is taught ?
Ask the patient to describe or repeat back in his or her own words what has just been told or taught. Return demonstration is a similar technique used by diabetic educators, physical therapists, and others. When the health professional hears the patient’s description in her/his own words, further teaching can be accomplished to correct misunderstandings. Never ask whether patients understand; they always say “yes”.
“I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure I did?”
“I want to make sure I explained this clearly. When you get back home in a few days, what will you tell your [friend or family member] about [key point just discussed]?”
“We covered a lot today about preventing falls, and I want to make sure that I explained things clearly. So let’s review what we discussed.What are three strategies that will help you prevent falls?”
“I want to be sure that I did a good job of teaching you today about risk for falls. Could you please tell me in your own words what you are doing to prevent falls? How you will prevent falls in the future?
Teach Back Question Card #3 Teach Back Question Card #4
Teach Back Question Card #1 Teach Back Question Card #2
Teach Back Language
When “Teach Back” Is Especially Important:
• New medications
• A new diagnosis
• Instructions for calling for help to BR
• Instructions for self care – e.g. ask, “How can you stay safe from falling in the
hospital?”
• Patients are cautioned on how to prevent falls in the hospital– e.g. young male patients who suddenly have high doses
of pain meds but want to toilet themselves. Ask, “How will you best prevent yourself from falling when you are given this powerful drug for pain that is known to cause falls?”
Ask Me 3®
http://www.npsf.org/askme3/
1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?
Ask Me 3® – Adapted for Falls
How many patients understand what we teach them?
• Teach patients with this format:1. Their main problem putting them at fall risk
2. What they need to do to keep from falling in hospital
3. Why is it important for them to do this
• Check the family‘s understanding: 1. What is the patient’s main problem?
2. What can the patient to do to stay safe from falling in the hospital?
3. Why it is important for the patient to do this?
Teach Back in Action – 7 key points
Teach Back in Action – 7 key points
Knowledge Test
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Return Demonstration
Teaching: After a Fall
• Reframe patient education curricula to include "what happens after a fall".
• What can we learn from this event?
• How can we work together to prevent this again?
Evaluating Your Teaching
• A one time test of knowledge - is that enough?
• Do you teach a diabetic patient how to manage diabetes one time?
• Isn’t fall risk management complex?
• Why did we start using “non-compliance?”
• I can teach a Stroke Patient how to safely transfer – Why? But how you teach a right brain CVA is different than a left brain CV
Patient Educational Materials
• CDC STEADI– Staying Independent: Are you at risk? (English)– What you can do to prevent falls (English, Spanish, Chinese)– Chair Risk Exercise (English, Spanish)– Postural Hypotension (English, Spanish)– Check for Safety Brochure (English, Spanish)
• VA National Falls Toolkit / VISN 8 PSCI (Patient Safety Center of Inquiry)– Hip Protectors (video and brochure; pts and caregivers)– Osteoporosis and Men (video)– Blood Thinners: What to do if you fall– What to do when you fall– Wall of Education Materials– Group Classes – How to fall and how to get up
Patient Educational Materials
Fall Prevention Tips for Hospital Patients and Families
Toolkits and Best Practice Recommendations for Fall Prevention
VA NCPS Falls Toolkit
AHRQ FallsPrevention Toolkit
ICSI Prevention of Falls Protocol
Ganz DA, et al. Agency for Healthcare Research and Quality. 2013.
VA National Center for Patient Safety (NCPS). 2014.
Degelau J, et al. Institute for Clinical Systems Improvement (ICSI). 2012.
IHI Reducing Patient Injuries from Falls
How-to Guide
Boushon B, et al. Institute for Healthcare Improvement. 2008.
To Change Practice is Not for the Faint of Heart!
But.. You can change your teaching!
Evaluation of Learning
• Design patient education program evaluation as a knowledge and skills checklist for cognitive and psychomotor domains of learning.
• Include Health Literacy Assessment to check ability to comprehend and use health information
Pat And Her Mom
Getting ready to dance
Implementing Teach Back at Summit Healthcare
Ruth A. Zimmerman RN, MSN, CPPSPatient Safety Manager
Nanette Garvin, RN, BSNProfessional Development Specialist
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About Us
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We are a not-for-profit rural healthcare organization serving the White Mountains of northeastern Arizona since 1970. Our 89-bed hospital includes a 32-bed Emergency Department, Level II Nursery, 12-bed ICU, medical/surgical and telemetry units, cardiac catheterization lab, Perioperative Services including a 4-suite OR, hybrid room, and special procedures rooms. We also have a strong presence in the community via outpatient clinics, physician offices, and various outreach programs.
Larry’s Story
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Why Teach Back?
• Recognized by AHRQ in 2001 and others as an evidence-based patient teaching strategy and top safety practice
• Requires active participation by the patient/family, which is known to increase learning and retention of material taught
• A mechanism by which patient/family readiness for discharge and ability for self-care can be assessed – The right thing to do
– May play a role in decreasing readmissions
• Varying degrees of overall literacy and profound shortcomings in health literacy often related to education, language preference, age, ethnicity, low socioeconomic status
• Patients at highest risk often have multiple
comorbidities which compound their
lack of understanding
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Our Teach Back Tale
• We have been very slow to adopt
• Requires understanding that yes/no questions will not validate patient understanding
• Focus on Nursing, but certainly opportunities in other disciplines
• Some staff already using this method but unaware they were doing so
• Teach Back used as a tool to teach Teach Back in nursing orientation and mandatory skills fairs
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Respecting Patient Autonomy in ED
• Shifting focus to respect patients’ right to refuse aspects of fall prevention program, while still providing staff with useful tools
• Willingness to accept that some patients will make bad choices
• Meeting in the middle • Installing curtains in ED bathrooms
• Placing bedside commodes in as many
rooms as possible
• Providing signage outside of rooms
to communicate various risks
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Educating the Inpatient
• Robust inpatient fall prevention program
• Many possible interventions
• All employees taught about program
• Patients assessed at regular intervals
• Fall rates well below benchmarks
• Patient/family education a relative weakness– No real tools to assist staff
– Lack of standardized language
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The Falls Agreement
• Developed and implemented by the Fall Team
• Reminds patients that even simple acts become more difficult in the hospital setting
• Asks patients to partner with us in keeping them safe
• Patient/family signature
• Posted in the patient room
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Implementation Hurdles
• Lack of staff familiarity with Teach Back and its importance to patient understanding
• Staff reluctance to use scripted language
• Original fall agreement written at high reading level (12+) and not well used by staff
• Revised agreement at more appropriate reading level but still not used extensively
• Agreement now included in patient admission packet
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Learn from Our Mistakes
• Engage staff more fully in the development process
• Solicit buy-in from unit leadership: directors, charge nurses, champions
• Tell the story of “why”
• Continue to educate and monitor until fully implemented
• Provide practice sessions, perform unit rounding and audits, solicit input
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Where to Next?
• We still have work to do in making sure Teach Back is being used across the organization
• Educate staff on the use of the fall agreement
• Consider a fall agreement for ED patients
• Questions? Please contact us!– Ruth Zimmerman: 928-537-6708 or
– Nanette Garvin: 928-537-6571 or
• Thank you for your time!
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Take a Moment…..
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Please Chat in the Box
What are some practical applications of today’s presentation that you can implement in your acute setting to reduce falls among your patients?
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Tips to make teach back stick
• Questions for the presenters and participants:
– How did you overcome staff reluctance to use a script?
– How did you support staff assessing cognition and using teach back on appropriate patients?
– How is the use of teach back monitored?
– Where is the result of teach back documented in the health record?
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Polling
What component of the presentation did you find most applicable to assist you with improving your patient education program for falls?
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Patient education and materials
Front line staff engagement, and program development and implementation
Best practices: “Teach Back”, Ask Me 3
Evaluating health literacy in existing education materials
All of the components of the presentation are applicable to my acute setting and will help me improve my patient education program for falls
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Bring it Home
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ResourcesTeach Back and Health Literacy Resources• AHRQ Literacy Universal Precautions Toolkit
• Ask me 3
• Always Use Teach-back! Website – includes competency checklist, training tools
Dr. Patricia Quigley’s Article• Article: Autonomy and the patient's right to choose falls prevention
Sample Patient Agreements• Prevent a Fall: Patient Agreement
• CoxHealth Patient Agreement
Patient Education Tool• Fall Prevention Tips for Hospital Patients and Families
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Falls Resources – Hospital-Wide LISTSERV®
• Join the LISTSERV®
– Ask questions
– Share best practices, tools and resources
– Learn from subject matter experts
– Receive follow up from this event and notice of future events
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Thank You!
Find more information on our website: www.hret-hiin.org
Questions or Comments: [email protected]
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