Appendix I: Action Plan for Sustainability Template
The completion of the Sustainability Action Plan by your team and the related discussion will enable you and your team to identify and remove barriers to sustainability and monitor progress on an action plan over the next 6 months.
Step 1: Based on your review of results of PDSA tests of change conducted during Action Period of the Falls Facilitated Learning Series, create an Action Plan with goals, target dates and persons responsible for monitoring. Your improvement team should take into consideration:
Goals that are the top priorities for Falls improvement work to be sustained over the next 6 months,
Strategies to avoid or limit the factors found to be barriers to Falls improvement work within your organization,
Strategies to utilize and enhance the factors found to facilitate Falls improvement work within your organization.
Step 2: Schedule a meeting with the Executive Sponsors, Project Leads, Improvement Advisor and other members of the improvement team and as a team, reflect on your goals for next six months work.
Action Plan Template:
Organization Name: NOR-MAN Regional Health Authority
Identify Improvement Team Members:
- Karen Leifso (Lead)
- Nellie Brown
- Darlene Larsen
- Diane Chambers
- Kelly Elvin
- Joanne Roberts
- Pat Kerwin
- Lois Moberly (Team Sponsor)
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 # of falls
Decrease the severity of injury /
- Continue to track and report on the number of falls and the severity of injury
- Debrief staff post falls to discuss triggers and possible interventions
Managers/Charge nurses / Review data on a ¼ bases to monitor until we reach our goal or reducing by 20%
Ensure that care plans are specific in regards to identifying triggers and care planning accordingly /
- Auditing care plans for specificity of interventions
- Debrief staff post falls to discuss triggers and possible interventions
- Initial the Morse fall Risk assessment/Intervention/Care plan.
Ongoing
Ongoing / Audit committee
Managers/Charge nurses
Staff / Do monthly audits on all falls to have 100% compliance
Link Morse fall scale to Careplan/Interventions / Auditing charts to see if Morse Fall Scale done / Ongoing / Audit committee / Do monthly audits on all falls to have 100% compliance
To link interventions based on level of risk to fall /
- Auditing charts to see if appropriate level of interventions have been chosen
- Auditing charts to see if interventions linked to Morse Fall Scale
April 2012 / Do monthly audits on all falls to have 100% compliance
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
Educate every staff member on the revised FPMP / Run education session for all staff / Sept 2012 / Karen Leifso
Nellie Brown
Managers / Monitor the % of all staff in acute care that require training and make sure all receive training
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