Www.saferhealthcarenow.ca Rapid Fire Team Presentation Template Name of Presentor: L.Winnett RN BHScN ADOC

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Rapid Fire Team Presentation TemplateName of Presentor: L.Winnett RN BHScN ADOC


Falls Facilitated Learning Series

Name of Organization: Lakeside Long Term Care

Location of Facility: Toronto, Ontario127 Long Term Care, consisting of 4 units of 32 residents each1 Respite

Who We Are



AIM

From Lakeside LTC Team Charter•Reduce the fall rate per 1000 resident days from 6.68 to 5.35, a decrease of 20% and maintain this decrease for a period of three months•Reduce the % of falls causing injury from the base line by 20%•Maintain the current 100% of residents with completed falls risk assessment on admission. (continued)


Falls Facilitated Learning SeriesAIM (Cont)

• Achieve 100% of residents who are “at risk” with a documented falls prevention/injury reduction plan from a baseline of 26.98%

• Achieve 100% of residents with a completed falls risk assessment following a fall or significant change in medical status from a baseline of 20.59%

• Maintain the number of residents with restraints in place at baseline or below.

AIM



Team Members

Team Member Role

Team Member Role

Donna Lee Administrator Team Sponsor

Lynn Winnett RN BHScN Team Lead

Sudhir Kurup PT Team Member

Ramil Rodreiquez PTA Team Member

Barbara Palwicz RN Team Member

Toni David Restorative Aide

Team Member

Jillbert Racadag OT Team Member



Review Falls Change Ideas tested to date in your organization

Changes Implemented within Organization

Working/Not Working Facilitators/Barriers identified

CQI log-develop and trial a data collection form that will capture all the relevant data that is needed for falls related reports, ease of trend identification, marked increases or decreases etc.

Working Only the person who created the log understand all the terminology and /or criteria behind the different areas of data, therefore needed to include a legend

Care Plan updating- Plan was for one person to do a blitz and bring compliance up to 100%

Worked, 100% achieved Was not sustained due to factors such as roles not clearly identified, changes to computerization, plan for sustainability was not built into the initial plan



Review Falls Change Ideas tested to date in your organization

Changes Implemented within Organization

Working/Not Working Facilitators/Barriers identified

Created a checklist for the registered staff to se when doing safety rounds that identify the specialized falls prevention needs of individual residents

Working Nothing at bedside to readily identify individual falls prevention items that should be in place i.e. fall out mats, personal alarms, no checklist for charge nurses to easily refer to when doing rounds/checks



MeasuresAIM: Reduce the fall rate per 100 residents days by 20% from a baseline of 6.68 to a target of 5.35Results: Target met in November 2011 but slightly elevated in Dec. Working towards goal.

Fall rate per 1000 resident days Lakeside LTC 2011

0123456789

1 2 3 4

Sept. Oct. Nov. Dec.

Fal

l ra

te p

er 1

00 r

es.

day

s

Your Result

Result-National


Falls Facilitated Learning SeriesMeasuresMeasures

# of falls per quarter 2011

0

5

10

15

20

25

# of falls per quarter 2011 21 20 18 8

1 2 3 4

J

•. Decrease in the number of witnessed falls by 13 or 44.8% over the course of 2011.


Falls Facilitated Learning SeriesMeasuresMeasures

# of repeat fallers

0

5

10

15

20

# of repeat fallers

# of repeat fallers 8 19 14 9

1 2 3 4

• Decrease in the number of residents who had repeat falls per quarter from a high in second quarter at 19 to a low in Oct. Nov. Dec of 9.



# of residents who had more than one fall

0

2

4

6

8

10

12

Month 2011

# o

f re

sid

en

ts

# of residents who had morethan one fall

•Decrease in the number of residents who had repeat falls with in the month from a high of 10 to a consistent number of 3 for Sept. Oct, Nov. and Dec. However the lowest level is 1 in March.

MeasuresMeasures



• AIM: To maintain 100% of residents with a falls risk assessment on admission

• Results: A drop in Nov. to 75% indicative of 1 out of 4 admissions not having a falls risk assessment completed

MeasuresMeasures

% of residents with a completed fall risk assessment on admission Lakeside LTC 2011

0

20

40

60

80

100

120

1 2 3 4

Sept. Oct. Nov. Dec.

% o

f re

sid

ents

Your Result

Result-National



• AIM: Achieve a percentage of 100% for at risk residents with a documented falls prevention/injury reduction plan

• Results: Based on the decision of the falls prevention committee this area did not become a focus until Nov. 2011 which lead to the achievement of 100% in December 2011. (Series 1 is the number of residents at risk and Series 2 is the number of residents with a plan in place).

Measures

Number of at Risk residents with a documented falls prevention/injury reduction plan

0

20

40

60

80

100

120

140

Sep-11 Oct-11 Nov-11 Dec-11#

of re

side

nts Series1

Series2


Falls Facilitated Learning SeriesMeasures

• AIM: to reduce to the number of falls causing injury by 20%

• Results: Lakeside has met its target of 19.2% which would be a reduction of 20% and now we will continue to work towards a new goal of less than 10% of falls resulting in injuries.

Number of falls causing injury

0

5

10

15

20

25

30

Sep-11 Oct-11 Nov-11 Dec-11

# o

f # of falls per month

# of falls causing injury

Measures

% of falls causing injury

0

5

10

15

20

25

30


% Your Result



• Prevalence of falls risk at Lakeside LTC facility wide as of Oct. 31/2011

MeasuresMeasures

Resident Falls Risk Level as of October 31, 2011 Lakeside LTC

0

10

20

30

40

50

60

70

80

Swan Heron Robin Cardinal Facility

# o

f re

sid

en

t

Low

Medium

High



Measures

Lakeside LTC Falls Prevention Program

0

10

20

30

40

50

60

70

Swan Heron Robin Cardinal Facility

# o

f re

sid

ents Butterfly Program

Floor Matts

Personal Alarms

Hi/Lo Bed

Hip Protectors



• AIM: Maintain the % of residents with restraints at baseline or below the number

• Results: Lakeside has consistently maintained the % of residents with restraints below baseline for Oct. Nov. and Dec. and below the provincial mean (as per data for FFLS)

Measures

Comparison of the % of residents with restraints as an organization and provincial FFLS 2011

0

5

10

15

20

25


% o

f re

sid

en

ts w

ith

restr

ain

ts

Mean Performance -Organization andProvince Your Result

Mean Performance -Organization andProvince Result-Province



• What were some barriers? 1. Recently switched over to computerized

documentation resulting in mixed forms of documentation and more of a challenge to follow up.

2. Inconsistent follow thorough from shift to shift

• What are some facilitators? 1. computerized documentation 2. support of the management

Challenges to Sustaining Falls Improvement



• How do you propose to move forward?Goals for 2012:maintain current trend whereby the number of falls related incidents decreases by

20% in 2012 from a total of 284 to 228 or less.maintain current 100% compliance with care planning for low, medium and high

risk residents.maintain current 100% post falls analysis and falls risk assessment post fall and

change in statusreduce the number of falls causing injury by 20% from 15 to 12 (using severity

harm scale)decrease the number of falls/FOF on day shift by 50% from 74 to 37 by the end of

2012.




Future Projects for Falls prevention program 2012:1. individual resident bedside cards for falls prevention strategiespamphlet for residents and families to be included in the admission package and

handed out to all current residents/families outlining the falls prevention program, what they can do to help us and what we can do to help them

2. target boards for each unit to measure their successes in achieving individual unit goals

3. development and distribution of the Personal Support Workers Falls prevention handbook (courtesy of RNAO best practice)

4. Re format monthly log forms and CQI reporting form to reflect current reporting data and facilitate ongoing auditing and tracking




6 Month Post FFLS Sustainability Plans for Falls Improvement Work

Goal Description

(What is AIM)

Action

(What STEPS are to be taken to achieve)

Timeframe

(When to be done by)

Person Responsible Metrics: What is to be monitored to identify achievement

Decrease the number of repeat fallers to zero and maintain this for a period of three months

Unit Focus groups for each repeat faller

Monthly basis Headed by falls prevention chairperson and PT

Number of repeat fallers per month



6 Month Post FFLS Sustainability Plan (continued)

Goal Description

(What is AIM)

Action

(What STEPS are to be taken to achieve)

Timeframe

(When to be done by)

Person Responsible Metrics: What is to be monitored to identify achievement

Decrease the number of falls events occurring on the day shift by 50%

Monthly falls prevention committee,

Education for day staff, identify possible causes for increased falls on day shift

Next six months Falls committee, all days staff, nurse educator, PT, OT

Number of falls events occurring on day shift

Increase staff, resident and family awareness of our falls prevention program and what their role in the prevention of falls

Develop an information phamplet to include in the new admission package, create individualized resident room cards, include discussions at care conferences and every time the resident has a fall with the resident and his/her family

Over the next six months Nursing staff, ADOC, Survey pre and post of current resident/family awareness.



1. When you are developing a plan of change make sure to include plans for sustainability from the very beginning.

2. Introduce program changes/targets in smaller pieces for increased staff compliance.

3. Allow the staff to have input into the change process

4. Have clearly defined roles and responsibilities to ensure accountability and completion.

5. A successful falls prevention program requires designated resources to for optimal results to be achieved.

Lessons Learned/Key Insights



Name: L.Winnett RN BHScN ADOC

Email: [email protected]

Contact Information

Documents

Www.saferhealthcarenow.ca Rapid Fire Team Presentation Template Name of Presentor: L.Winnett RN BHScN ADOC