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Implementation ExampleFall/Fall Risk Clinical Process Guideline
Joint Provider/Surveyor Training
September 15, 2009
Karen M. Kinyon, M.S., R.N., C.P.H.Q., N.H.A.
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FOCUS-PDCA
• Find a process improvement opportunity• Organize a team who understands the
process• Clarify the current knowledge of the process• Understand process variation and
capability • Start the Plan-Do-Check-Act cycle
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Find a process improvement opportunity
• High risk • Problem prone• Previous citations• Rank order all clinical process guidelines
based on previous quality findings• Implementation plan for all guidelines
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Organize an effort to work on improvementTeam/Group Make-up
• Geriatric Resource Nurse• Director of Nursing/Assistant DON• Unit Managers• Maintenance/Safety Champion• Pharmacy• Medical Director• Staff Educator• Social Work• Admission Coordinator/MDS Coordinators• Restorative Staff
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Clarify the current knowledge of the process
• Clinical Process Guideline interpretation– Debra Ayres presentation– Clinical Process Guideline Team members– Review CPG
• Care Step Process/Expectations/Rationale
• Documentation Checklist: Audit tool• Tables 1, 2, & 3
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Understand process variation andcapability
• Current practice compared to best practice• Data collection• Data analysis/display• Identifying opportunities for improvement
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Opportunities for Improvement
• Fall assessment• History of previous falls• Medication-recent change, interactions• Appliances or devices-side rails • Environmental factors-floor mats, transfer bars• Physician participation in identification for
medical cause of falls or medication related• Physician identifies reasons for falls after
interventions7
Select a strategy for continued improvement• Plan the improvement process• Do the improvement• Check the results and lessons learned• Act by adopting, abandoning or accepting
the change
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Plan the improvement process
• Culture of safety• Resident & staff understanding of a safe
environment• Positioning and bed safety• Documentation
• Physician• Pharmacist• Nursing
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Do the improvement
• Policy & procedure review/revisions• Education of staff• Education of residents/families• Assessment & evaluation of current side rail
use • Assessment & evaluation of equipment• Purchase of new equipment• Revision of forms• Development of new tools 10
Policy & Procedure Changes
• Resident Safety Report• Investigation and Intervention Report• Physical Safety: Sleeping Environment• Physical Safety: Restraints• Physical Safety Assessment & Admission
Procedure• Learning Tree
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Forms/Brochure
• Resident Safety Report• Investigation and Intervention Report• Physical Safety Assessment• Learning Tree• Resident/family brochure: Restraint Use in
the
Long-Term Care Setting
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Education
• Resident Council/Family• Resident/Family Brochure• Staff
– RNs/LPNs/CNAs – Maintenance– Housekeeping– Activities– Therapy• Education/Resource Manual• Orientation Manual
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Check the results/lessons learned
• Follow-up data collection• Cost of change
– Brochures– Positioning devices– Floor mats– Hand controls– Time
• Change is difficult14
Act by adopting, abandoning or accepting the change• On going training/education
– Staff– Residents/families• Future state = no side rails• Reinforcement of change• Can’t go back• Celebrate success• On going monitoring and data collection
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Resources
• Process Guideline for Evaluation of Falls/Fall Risk http://www.michigan.gov/documents/mdch/bhs_CPG_Falls_Process_206279_7.pdf
• AMDA Clinical Process Guidelines, 2003.
• Centers for Medicare & Medicaid Services, State Operations Manual,
Guidance to Surveyors for Long Term Care Facilities (2006) http://cms.hhs.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf.
• TMF Health Quality Institute, the Medicare Quality
Improvement Organization of Texas-LTC Ombudsman
Initiative: Restraint reduction Toolkit, 2007
http://nursinghomes.tmf.org/Restraints/RestraintToolkit/tabid/548/Default.aspx.
• MDCIS Guidelines for Use of Bed Rails in Long Term Care Facilities (March 1, 2001) http://www.michigan.gov/documents/cis_bhs_fhs_guidelines_bedrails_35726_7.pdf.
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