Implementing Change in Patient Safety Preventing Fall Related Injuries: How to

Sustain and Spread Improvement

Patricia Quigley, PhD, MPH, ARNP, CRRN,FAAN, FAANP

Describe strategies to effectively implement changes in patient safety

Describe program evaluation for fall and injury reduction

3 Form a Team

System Leadership

Technical Expertise

Day-to-Day Leadership

Examples of Team Members for Fall Related Injury Prevention

Nursing (RN, LPN, Aid)

Physical Therapist, Occupational Therapist

Pharmacist

QI and/or Systems Re-Design

Mental Health Provider as Needed

Home Care Staff as Needed

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

ACT PLAN

DO STUDY

Setting Aims

Leading Change

Establish a sense of urgency

Create a vision Communicate

the vision

Empower others to act

Plan for and create short term wins

Consolidate improvements

Institutionalize new

approaches

State the Aim Clearly

Teams make better progress when they are very specific about their aims.

Achieving agreement on the aim of a project is critical for maintaining progress.

Must Be Measurable!

Goals

Polling Question 1

I am aware of my facility’s fall and fall related injury rate:

A) Yes

B) No

Keep explicitly communicating the stretch goal!

Avoid Aim Drift

Examples of Aims

Reducing the rate of falls in our

facility by 40% in seven months

Reducing the rate of injuries due to falls in our facility

by 50% in 7 months

Increase the percentage of staff

on our unit who are educated

about our falls prevention

protocol to 100% in 2 months

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

ACT PLAN

DO STUDY

Was the Change an Improvement?

Measure Process

Measure Outcome

Patient focus?

Aim? Find a measure that captures that change?

Tips for Measurements Seek usefulness, not perfection.

Use sampling . Ex: 10 charts per week.

Don’t wait for the information system.

Reports percentages & rates, not absolute numbers.

Take outcome measures at least 1 X/month.

Take process measures at least 2 X/month.

Plot data over time, run charts.

Examples of Process Measures

Percentage of

• Patients at risk for falls and fall related injuries with interventions in place

• Patient with completed intentional rounding

• Observation, chart review

Process measures answer the question: “Are we doing the things we think will lead to

improvement in outcome?”

Outcome Measures

Major Injury Rate

Fall Rate Balancing Measures

Polling Question #2

Leadership supports our fall and fall related injury prevention efforts:

A) Not at all

B) Somewhat

C) To a great degree

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Example of Process run chart

0

10

20

30

40

50

60

70

80

90

100

Jan-1

1

Feb

-11

Mar

-11

Apr-

11

May

-11

Jun-1

1

Jul-

11

Aug-1

1

Sep

-11

Oct

-11

Nov-1

1

Dec

-11

Jan-1

2

Feb

-12

Mar

-12

Apr-

12

May

-12

Jun-1

2

Jul-

12

Aug-1

2

Sep

-12

% o

f fa

ll r

isk

pa

tien

ts r

ecei

vin

g i

nte

nti

on

al

rou

nd

ing

% of fall risk patients receiving intentional rounding

Example of a Outcome Run Chart

0

0.5

1

1.5

2

2.5

3

3.5

Jan-1

1

Feb

-11

Mar

-11

Apr-

11

May

-11

Jun-1

1

Jul-

11

Aug-1

1

Sep

-11

Oct

-11

Nov-1

1

Dec

-11

Jan

-12

Feb

-12

Mar

-12

Apr-

12

May

-12

Jun-1

2

Jul-

12

Aug-1

2

Sep

-12

Fa

lls

wit

h M

ajo

r In

jury

Ra

te (

fall

s w

/ma

jor

inju

ry/B

DO

C*

10

00)

Rate of Falls with Major Injury (#falls with major injury/BDOC*1000)

Increased rounding intervention

Month

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

ACT PLAN

DO STUDY

Characteristics of the Innovation • Relative Advantage - How much better is the new

compared to the old?

• Compatibility - How consistent is this new idea with

values, past experience, and needs?

• Complexity - How difficult is this new idea to understand

and use?

• Trialability - how easy is it to test the new idea?

• Observability - How visible are the results of this new

idea?

• How much better is the new compared to the old?

Relative Advantage

• How consistent is this new idea with values, past experience & needs?

Compatibility

• How difficult is this new idea to understand and use?

Complexity

• How easy is it to test the new idea? Trialability

• How visible are the results of this new idea?

Observability

What type of person is adopter? • Adventurous, associate with other

innovators, occasionally suspect Innovators

• Well respected, opinion-leaders, role models

Early Adopters

• Not opinion leaders, think about it awhile, interact with peers

Early Majority

• Require peer pressure Late

Majority

• Suspicious of new ideas, look to past vs. the future, sometimes isolated

Laggards

• YOU are the bridge

• Show the need to change

• Develop rapport

• Work through opinion leaders

• Communicate

• Answer the questions

Change Agents

YOU are the Bridge

Show the Need to Change

Develop Rapport

Communicate

Work Through Opinion Leaders

Answer the Questions

Testing on a Small Scale

PD

SA Exam

ple

s Try hip protectors on 5 patients

Show a new assessment protocol to 2 staff members

and get feedback

Assess the walk to the bathroom in 2 rooms

Pilot floor mats on 2 patients

Implement an environmental

assessment on one unit or in the facility

Send out cards with a new falls

prevention program to staff

Give all patients on the unit literature

on falls

NOT PDSA Examples

Increase the belief that the change will result in improvement in your environment

Predict how much improvement can be expected from the change

Learn how to adapt the change to conditions in the local environment

Evaluate costs and side-effects of the change

Minimize resistance upon implementation

Why test using PDSA?

• Process by which individuals work together to improve systems and processes with the intention to improve outcomes*

*Committee on Assessing the System for Protecting Human Research

Participants. Responsible Research: A Systems Approach to Protecting Research Participants. Washington, D.C.: The National Academies Press: 2002.

Program Evaluation Process

32

Organizational Level: Expert interdisciplinary all team, program evaluation, leadership, environmental safety, safe patient equipment, anti-tippers on wheelchairs

Unit Level: education, communication-handoff, universal and population-based fall-prevention approaches

Patient Level: exercise, medication modification, orthostasis management, assistive mobility aides

Program Effectiveness: Fall Prevention

• Organizational Level: available helmets, hip protectors, floor mats, height adjustable beds; elimination of sharp edges

• Staff Level: education, adherence, communication-handoff includes risk for injury

• Patient Level: adherence with hip protector use, helmet use, etc.

Program Effectiveness: Protection from Serious Injury

• Prevalence Studies

• Formative and Summative Evaluation Methods

– Type of Falls

– Severity of Injury

• How are you assessing for injury? Duration? Extent of Injury?

– Repeat Falls

– Survival Analysis

– Annotated Run Charts

Evaluations Methods

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Effectiveness of Post Fall Huddles: Repeat Fallers

A Special Emphasis Population

• Specify Root Cause (proximal cause)

• Specify Type of Fall

• Identify actions to prevent reoccurrence

• Changed Planned of Care

• Patient (family) involved in learning about the fall occurrence

• Prevent Repeat Fall

Outcomes of Post Fall Huddles

• Is your program improving?

• Are your patients safer?

• Are your patients confident?

Painting the Picture

Pat And Her Mom

Getting ready to dance

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