Improvement Charter

Team Name: /

Cypress Health Region Long Term Care Falls Prevention Team

Team Members: /

Linda Creighton, Danetta Warberg, Shirley Weinbender, Shannon Benjamin, Penny Flynn, Tonie Shea, Karen Bennett, Gena Hodgins, Janie Gillis, Elaine Garies, Jackie Vanstone, Raylene Elsasser, Lindsay Schneider, Lindsay McGregor, Cynthia Philip, Diane Broks, Angela Muzyka (multidiscplinary team)

Team Leader: /

Diane Broks – Director Clinical Practice

Team Sponsor: /

Gloria Illerbrun – Executive Director Health Services

WHAT ARE WE TRYING TO ACCOMPLISH? /

Purpose of Project

To decrease the # of residents that fall in Cypress Health Region Long Term Care facilities by 30% by March 31, 2012.
Scope & Boundaries
  • The program will be implemented in 100% of our LTC facilities by July 31/2011.
  • Time
  • Staffing
  • Ministry targets
  • MDS data – not valid
  • Limited access to professional staff
  • Scope of practice
/
  • Budget/lack of education budget
  • Family, staff, physician resistance
  • Financial - resident resources
  • Regional barriers - policies

Improvement Objectives
By March 31st/2011
  • Decrease the severity of injury as a result of falls
  • Decrease the # of deaths as a result of falls
  • Ensure that restraint use does not increase
  • Work towards consistent reporting/documentation
  • Increase communication/education with staff, family and residents
  • Empower staff to suggest and trial changes
  • Ensure compliance with regional restraint policy

HOW WILL WE KNOW A CHANGE IS AN IMPROVEMENT? / Measures
  1. Falls Rate per 1000 Days
  2. Percentage of Falls Causing Injury
  3. % of Residents with Completed Falls Assessments
  4. % Completed Risk Assessments after Change in Status
  5. Percentage of “At Risk” Patients/Residents with a Documented Falls Prevention/Injury Reduction Plan
  6. Percentage of Patients/Residents with Restraints
/ Current Performance / Goals
WHAT CHANGES CAN WE MAKE THAT WILL RESULT IN IMPROVEMENT? /

Change Concepts and Ideas to Test

Falls diary
Toileting Program
Identify falls by location – floor plan of facility
Hip protectors
3 questions
Improve communication within facility, with residents and families
Vitamin D (Tums)
Restraint Assessment
HOW WILL WE MANAGE THE IMPROVEMENT PROJECT? /

Principles for Working Together

Focus on prevention (proactive vs. reactive)
Respect amongst providers

Roles & Responsibilities

Data collection – Champions
Communication - Team
Documentation - Team
Monthly Reports – Project Sponsor
PDSA – All team members to trial
Auditing - Team

Review Schedule

Diane Broks/Angela Muzyka meet every 2 weeks to review progress
Review with Executive Director every 2 months
Report to CHR Board monthly
Teleconference with Regional Team -

Key Dates

Team Calls (Collaborative) 9-10am
  • June 16th/2011
  • June 30th/2011
  • July 21st/2011
  • August 18th/2011
  • Sept 15th/2011
  • October 20th/2011
  • November 17th/2011
  • December 15th/2011
  • January 19th/2012
  • Feb 16th/2012
  • March 15th/2012
Teleconference with Regional Team 9-10am
  • July 14th/2011
  • September 8th/11 (Face to Face??)
  • November 10th/11
  • February 2nd/12
  • March 1st/12
Learning session - 1 Part A May 26/11 Part B June 2/11
Learning session –2 October 24 + 25th/11 Saskatoon
Learning session –3 Part A Week of Feb 20/11 Part B Feb 28/11

Author: Angela Muzyka

Date: June 30th/2011

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