Project Name: Fall Prevention * this project was approved as part of the Quality Safety Plan in Aug 2010 Overall Timeline: 12 – 18 Months Updated Dec 2011

Exec Lead: Carole Moore / Project Lead:Mary Lou James / Physician Lead:Dr. D. Austin
Core Team Members: Nancy Fletcher, Jean-Marie Chan Kin, Sharon Tai-Young, Roger Perez, Suzanne Vanderlip, Narinder Kainth, Katie Adams, Lindsay Yan, Mary Tang Project Consultants: Dr. Austin / Background and Context:
1. 2 serious falls in Fall 2010 / Spring 2012 has resulted complete revision of the fall prevention policy in MSHC and a heightened profile of preventable falls as a corporate priority
Immediate modification of current policy occurred in Dec/2010:
·  increased assessments from once per week to daily
·  develop processes; revised policy; created Meditech 6.0 screens and educated staff on new Post Fall interventions
2. A complete revision/new policy prepared (Jan- April 2011) and will be rolled out in May- July 2011). Includes:
·  iInclude broadened clinical areas; including (Adult inpatient – OBS, PAEDs, ED, Peri-op and out patient areas)
·  evidenced based; area/unit specific risk assessment and intervention strategies; including post falls monitoring
·  includes detailed communication and documentation tools / strategies
3. Goals of the 2011 Falls Prevention Strategy will be to:
-standardize assessment and prevention, and intervention and post fall strategies and practice
-increase compliance with fall risks assessments and post falls monitoring in all clinical areas (measured by audits)
-use multi modal education/Champions for roll out /to increase clinical use
-examine practice and economic implications of using an evidenced based nursing best practice guideline to improve outcomes and avoid extra costs spent due to falls
-capture data for IHI Cost +Quality initiative project / 2. Project Objective and Scope.
To:
-decrease the the # of fall incidents per 1000 patient days in MSHC, thereby lowering costs, morbidity and mortality through the revised corproate policy, targeted education and communication regarding falls risk assessment and prevention
-decrease morbidity and mortality due to preventable falls during hospital admission
- decrease Length of Stay (LOS) of all clinical areas
-network with teams in a Community of Practice through SHCN/ RNA O-Falls Facilitated Learning Series (FFLS) / Performance measures related to quality, safety, cost others / Baseline / Sept
2011 / Oct
2011 / Nov 2011 / Dec
2011
1. Decrease falls rate by 12% to 4.0/1000 patient days / Aug 11
4.4 / 4.1
2. Reduce Serious Safety Events (severity level 4 falls) by 25% / Jan-Dec 10
= 7
3. Decrease avoid costs from fractured hip related to falls by 5 % (by standarizing care & decreasing LOS)
* Average Surgical costs per fractured hip repair:
•  Supply cost= $1170.82 per patient
•  Staff costs 2 to 3 nurses for 20 minute average= $496.80 per patient
•  Average LOS post hip surgery after fracture 6-9 days at approx $486.00/day. Average 6 days=$2,916.00 per patient / 5 falls resulted in fractures and surgical repairs
Estimate Cost x 5 patients=
$4,583.62x5=$22,918.11 / Reduce fractures due to
falls by 1-2
Potential cost avoidance
savings of
$4,583.62 x 2 =
$9,167.24 / tbd
4. Estimate cost of legal claims related to falls / Current claims of 300k to 1 mil / tbd
5. Compliance with fall risk assessment completed within 24hrs will be 100%. (results obtained by audit – all units) / Aug 11 – 85% / 87% / 94% / 94%
6. Compliance with fall risk assessment daily thereafter will be 100%. / Aug 11 - 87% / 87% / 96% / 93%
7. Compliance with falls prevention interventions (visual identifiers) followed is at 100%. / Aug 11 - 86% / 58% / 71% / 72%
8.  Decrease by 20% falls causing injury
* SHCN/RNAO data on selected units(3C, 3E, 1C, 1E, UXB) / Aug 11- 8.3% / 5.0% / 13.04% / 8.3%
9.  Compliance with at risk patients having a documented Fall prevention /injury reduction plan will be 100% on selected units(3C, 3E, 1C, 1E, UXB)
* SHCN/RNAO data / 96.70% / 94.87% / 95.43% / 91.71% / xx
10.  Compliance with fall risk assessment completed within 24hrs will be 100% on selected units(3C, 3E, 1C, 1E, UXB) * SHCN/RNAO data / 83.65% / 83.96% / 85.87% / 82.98% / xx
4. Project Development and Implementation Timelines / 5. Project Devel. Implementation Costs
4a) Project Steps / Start/Stop Date / Dept/People Impacted or Support required / Time Commit est.) / Cost Item / Costs / Recurring
1. Complete Project Charter / Feb 28, 2011 / Prof. Practice, Decision Support, Health Information Management (HIM), Med MDs, VP-Clinical Programs / 5 days / 0 / 0 / N
2. Complete research / development of new policy / May 1, 2011 / PPLs, MDs, Directors, Managers & front line staff, VP-CP / 10 days
3. Present new Fall Prevention Policy at committees for endorsement / May – June 2011 / PPLs, MDs, Directors, Managers & front line staff, VP-CP / 5 days / 0 / 0 / N
4. Education/Communication roll out. Policy uploaded and “Live” June 21/11 / May – June 2011 / PPLs, MDs, Finance, Managers, front line staff / 2 days per year / $5,000 (materials) / 0 / N
5. Develop audit tool (update current); develop scheduling. Audit compliance and success in meeting performance measures / August 2011
Ongoing thru June 2012 / Prof Practice, Decision Support, HIM, Finance, Pharm, ED & Med, Chief of Staff, VP-CP / 3 days per quarter / 0 / 0 / N
6. Engage a Champion network to educate and audit falls prevention and management. / Sep 2011 / Prof Practice, Director,Quality Risk
7. Participate in SHCN/RNAO – FFLS – post data
·  input 3 measures to SHCN site
o  %falls causing injury (i-Report 3-5)
o  %pts with completed risk assessment at 24 hrs
o  % pts with documented falls prevention/risk reduction plan
·  Complete PDSA activities related to falls
·  Post Project Charter to SHCN site / Oct 2011 / Prof Practice, Director,Quality Risk
8. Evaluate effectiveness of fall prevention program / June 11 /June 12 / Prof Practice, Dec. Support, HIM, Finance, Pharm, ED & Med, Chief of Staff / 3 days per quarter / 0 / 0 / N
4b) Activities in first 120 day cycle if more detail needed than in 4a) to indicate impact on other dept/people or support required / Stop/Start Date / Dept/People Impacted: / Estimate Resource Time Commitment
6. Risks/Additional Comments: / Date Project Approved:

Project Charter – v3 –Nov 2010 Page 1