Improvement Charter

Project Name: /

Falls Prevention Virtual Learning Collaborative

Team Members: /

Nadia Kloc, Inpatients Nurse Manager; Heather Wall, Inpatients ANM; Carolyn Howe-Riddel, Inpatients Resource Nurse;Amy Kantor, Quality Consultant; Carole Szwajkowski, Nursing Education; Judy Poon, Rehab Medicine; Michelle Gardecki, Charge RN

Team Lead: /

Nadia Kloc

Team Sponsor: /

Paula Langenhoff, Leader Planning and Administration

WHAT ARE WE TRYING TO ACCOMPLISH? /

Purpose of Project

To lead and coordinate team learning, process and care improvements; to ensure our targeted goals are achieved in falls and injury reduction and that we contribute as active participants in the SHN Falls Prevention VLC.
Scope & Boundaries
  1. Patients at risk for Falls and Injury from falls.
  2. Patients admitted to the inpatient units within the Cross Cancer Institute.

Improvement Objectives
  • Reduce incidence of falls (fall rate) by 40% from baseline (to 2.4%) by March 2011.
  • Reduce injury from falls by 40% from baseline (to 19%) by March 2011.

HOW WILL WE KNOW A CHANGE IS AN IMPROVEMENT? / Measures
  1. Percentage of Falls Causing Injury
  2. Percentage of Patients with completed falls risk assessment on admission
  3. Percentage of “At Risk” Patients with a documented falls prevention/injury reduction plan
  4. Fall Rate per 1000 patient days
  5. Percentage of Patients with completed falls risk assessment following a fall or significant change in medical status
/ Current Performance
  1. 32% (April – August 2010)
  1. 0%
  1. 0%
  1. 4% (April – August 2010)
  1. 0%
/ Goals
  1. Reduce by 40% (19%)
  2. 100%
  1. 100%
  1. Reduce by 40% (2.4%)
  2. 100%

WHAT CHANGES CAN WE MAKE THAT WILL RESULTIN IMPROVEMENT? /

Change Concepts and Ideas to Test

  1. Implement Schmid Fall Risk Assessment Tool
  2. Educate staff on the importance of harm reduction and strategies
  3. Engage and educate housekeeping staff on the importance of furniture placement, wet floors, clutter, lighting, electrical cords etc.
  4. Develop organizational policy and procedure for falls prevention
  5. Involve patients and family in falls prevention and injury reduction planning
  6. Ensure equipment that is needed is available.

HOW WILL WE MANAGE THE IMPROVEMENT PROJECT? /

Principles for Working Together

  1. Demonstrate mutual respect
  2. Demonstrate commitment to project
  • Share the workload
  • Attend all meetings unless absolutely unable
  • Look for the opportunities and the keys to success rather that focusing on the limitations
  1. Communicate between all members
  • Minutes to reflect issues, discussion points, action steps, responsibilities
  1. Seek and listen to other’s perspectives and consider all input
  2. Engage Team Sponsor when barriers to implementation are beyond the team’s ability to address on our own
  3. Share successes with each other, the organization, and VLC members as everyone teaches and everyone learns
  4. Include other interested partners as identified
  5. Consult proactively with Collaborative Faculty through scheduled team Conference calls and office hours in action periods between Learning Sessions (avoid feeling overwhelmed)
  6. Connect, consult and exchange ideas and tools with other VLC Team Leads

Roles & Responsibilities

Team Sponsor
  • Clarify the improvement mandate and align with the AHS strategic and operational objectives
  • Connect and communicate with appropriate stakeholders
  • Support the development of the team charter with the Team Leader
  • Provide time and other resources
  • Establish an accountability or reporting mechanism
  • Facilitate the work of the team within CCI and AHS
  • Engage a team leader and serve as a coach for the Team Leader and the team
Team Leader
  • Complete and clarify the team charter in a manner that ensures the support of team members and team sponsor
  • Organize and lead effective meetings and maintain team records i.e. minutes, correspondence, improvement data
  • Facilitate work within the team and ensure participation at and between meetings
  • Serve as a communication link between the team and the team sponsor
  • Refer system issues to the Team Sponsor
  • Ensure data is collected, submitted, reviewed and used by the team
Team Members
  • Share practice and care knowledge, skill and experience
  • Communicate and develop a shared understanding within the team of the work/care process to be improved or changed
  • Identify and test change ideas with team colleagues and in actual care processes
  • Use the results and our learning from tests of change (PDSA cycles) to define our next test of change (lessons learned about what didn’t work as we projected it would is most helpful)
  • Lead and support coworkers to adapt to the new process
  • Complete tasks or assignments within and between meetings

Review Schedule

  • Review Team Improvement Charter at least once per Action Period and update as needed.
  • October (late)
  • December (early)
  • January (late) or February
  • Provide monthly progress update to Team Sponsor

Key Dates

Learning Session 1: October 5, 2010, 10:00
Learning Session 2: November 9, 2010, 10:00
Learning Session 3: January 25, 2011, 10:00
Learning Session 4 and Closing Congress: March 22, 2011, 10:00
Team WebexCalls
October 19, 2010, 11:00
November 30, 2010, 11:00
January 11, 1011, 11:00
February 15, 2011, 11:00

Date: October 19, 2010Author: A. Kantor

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