National Falls Facilitated Learning Series

National Falls Facilitated Learning Series

Team Improvement Charter November 2011

Project Name: National FFLS Learning Series

Team Members: Elaine Ferguson (PT), Ophelia Leung (OT), Cathy Wunderlich

(RN), Melissa Crozier (RN), Aimee Bourgoin (RN)

Team Lead: Aimee Bourgoin

Team Sponsor: Averil Suriyakumaran EG Site

Purpose of Falls Intervention Team:

To work on strategies to sustain the falls initiative in order to continue this organization’s commitment to Falls improvement. We want continue to prevent falls and create a safe environment for our residents, minimizing the use of restraints. To this end, we will submit our data to the FFLS as well as make our staff at the facility aware of the initiatives we are undertaking to sustain the Fall Initiative for Covenant Health at the EG site.

Scope and Boundaries:

Team members involved had been part of the previous falls initiative to a greater or lesser extent with residents at EG. The target will continue to be residents at risk for falls and injury at the site. Sustainability strategies will be for improving on the gains made from the previous strategy and embedding best practices for fall prevention and injury reduction into the site culture.

Improvement Aim:

To engage in fall prevention and injury reduction as team members working with the National FFLS to learn strategies and plan for sustained improvement reducing falls and injury from falls.

By March 2012:

Develop a plan for Falls Prevention and Injury Reduction for sustaining practice change.

Collect and submit data monthly on measures to Safer Healthcare Now! (SHN) in order to use data to monitor and facilitate sustained improvements.

Demonstrate a 15% improvement in baseline measures and sustain them for 3 consecutive months.

Measures for our healthcare setting:

Long Term Care Measures Current PerformanceGoals

1. Percentage of falls causing 13.21 % 11%

injury.(reduce by 15%)

1. Percentage of residents with93.3% 100%

completed fall risk assessment

on admission.

1. Percentage of “at risk” residents 73.3% 100%

with documented falls prevention/

injury reduction plan.

1. Fall rate per 1000 resident days.117.78 100.18

(reduce by 15%)

1. Percentage of residents with 0% 100%

completed fall risk assessment

following a fall or significant change

in medical status.

1. Percentage of residents with restraints 25% 21%

in place.(reduce by 15%)

What Changes Will We Make?

We determined that we need to reassess the risk piece of past practice in order to have staff place the priority on those residents at greatest risk of falling. That is, our past practice was to place a leaf outside the door of all residents who were at risk of falling. That usually meant that a number of residents on a unit were identified. What we will do now is target new admissions during a vulnerable initial two week period and also any actual fallers. We are wanting to revamp our existing Green Leaf program and extend it to be not just “ASK 3” but for our population, “What else?” before staff leave the room. After several years of use, we realize our screening tool also needs revamping so that interventions co-exist with the screen and so that we follow-up with those residents who have a change in their medical status using MDS. We want to change our staff orientation to include the revamped screening tool and revised Green Leaf program. We want to empower HCAs to give us feedback on interventions that we trial, including the screening tool and the Green Leaf program changes. We feel that report time is a critical time to talk about the risky fallers and so we will target and demonstrate that behavior as we go to the units. We will try to advocate for some system changes that can make a difference, for example a new call bell system in the older part of our building which would allow us to use bed/charm alarms more effectively. Our quality improvement statistics are not being reviewed and the information passed along to staff so that they see how the initiatives are working or not. We want to communicate our fall rates to staff so that they are part of the initiative. We will work with new managers to make them aware of how to review critical incidents, most of those relate to falls.

How Will We Manage the Improvement Project?

Demonstrate mutual respect, seek out and listen to other team member’s perspectives.

Hold regular meetings with minutes prepared.

Have a communication plan to reflect issues, discussion points, action steps and responsibilities.

Share the workload.

Include other interested partners that we identify.

Share successes with each other, the site and the organization.

Start small with our PDSA cycles and bite off manageable pieces, unit by unit if necessary.

Connect and consult with FFLS Faculty through scheduled team calls.

Team Roles and Responsibilities:

Team Sponsor

Will ensure that our strategies are aligned and embedded in the site and organization strategic objectives.

Provide resources in terms of clerical support and allow team members to participate in activities as a priority.

Establish a reporting mechanism within the site whether through meetings or a site newsletter.

Team Leader

Complete and share team charter in a manner that ensures support of team members.

Organize and lead effective meetings, maintaining records and improvement data.

Serve as the communication link between the team and the team sponsor.

Ensure that data is collected and submitted consistently to FFLS.

Team Members

Share practice and care knowledge, skill and experience.

Communicate and develop a shared understanding within the team of the work necessary to sustain the change in falls prevention and injury reduction for our residents.

Use PDSA cycles to define next changes and to test them.

Lead and support coworkers to adapt to new processes.

Complete tasks and assignments within and between meetings.