first, do no harm falls work
DESCRIPTION
First, Do No Harm Falls work. Karen O ’ Keeffe Clinical Lead Presentation 7 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC. Northern Region Charter – Our Direction. Phasing of Implementation. Issues - PowerPoint PPT PresentationTRANSCRIPT
First, Do No HarmFalls work
Karen O’Keeffe
Clinical LeadPresentation 7 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC
Northern Region Charter – Our Direction
Our Mission:
“To improve health outcomes and reduce disparities by delivering better, sooner, more convenient services. We will do this in a way that meets future demand whilst living within our means.”
FacilitiesWorkforceInformation Systems
Service Changes
National Health Targets
Informed PatientLife and YearsFirst Do No Harm
FacilitiesWorkforceInformation Systems
Service Changes
National Health Targets
Informed PatientLife and YearsFirst Do No Harm
Triple Aim Methodology
Population Health
Simultaneously
Patient Experience
Cost / Productivity
Population Health
Simultaneously
Patient Experience
Cost / Productivity
Phasing of Implementation
Review of 50 deaths
• Consistent regional QI/ Safety work• Implement agreed methodologies• Regional medication safety initiative• Implement outcomes based framework • Identify and progress next improvement priorities
Implement Global Trigger Tool
Stock take current QI / safety work & resources
Pilot site for medication safety
Initiate Campaign
Progress Campaign
Agree consistent methodologies:
• Falls• Pressure injuries
• CLABS• Transfers of care• Patient identification
CVD & Diabetes high risk patient registers
Cancer therapy wait time improvement
TumourPathway
Bowel screening pilot
Smoking cessation
Implement Region Colonoscopy prioritisation criteria
CVD prevention, screening, assessment initiative• Forecast tool • Primary care assessment and management
Minimise impacts from CVD• Service quality• Wait times• Rehab model
Diabetes prevention, screening, assessment initiative• Get Checked uptake• Retinal screening increase
Develop diabetes pathway
Mentor systems for Diabetes teams • 3 pilot sites • Audit feedback cycle• Links to CVD teams
Engage with Whanau Ora. Support development of Oranga Ki Tuaprogrammes for long term conditions
Implement Clinical Networks: Cardiac, Diabetes, Health of Older People
Promote aging in place• Implement InterRAI• Review home based support services•Transparent and consistent access to ARC
Review causes of ASH admission from ARC
Develop Clinical Pathways for cognitive decline
Bridging information gaps
Increase management plan uptake for CVD patients
Promote Advanced Care Planning• Engagement and awareness• Education and training• Systems• Roll out to priority groups
Whanau Ora• Complete assessments• Increase rate of Whanau with agreed goal oriented plans
Grow workforce for CVD and Diabetes
Implement Radiology clinical network• Paediatric radiology• Clinical pathways• Capital investmentDevelop long term strategy
for laboratory services
Information system priorities• Single PAS• Single clinical workstation • Clinical data repository• Population health data repository• IS infrastructure resilience
Progress development of Regional education, research and innovation initiatives
Implementation of effective governance •Supporting clinical leadership•Ensuring delivery of business and clinical plans
Life and YearsDo no Harm
Informed Patient
Key EnablersBetter patient engagement
Self management tools
Review of 50 deaths
• Consistent regional QI/ Safety work• Implement agreed methodologies• Regional medication safety initiative• Implement outcomes based framework • Identify and progress next improvement priorities
Implement Global Trigger Tool
Stock take current QI / safety work & resources
Pilot site for medication safety
Initiate Campaign
Progress Campaign
Agree consistent methodologies:
• Falls• Pressure injuries
• CLABS• Transfers of care• Patient identification
Review of 50 deaths
Review of 50 deaths
• Consistent regional QI/ Safety work• Implement agreed methodologies• Regional medication safety initiative• Implement outcomes based framework • Identify and progress next improvement priorities
Implement Global Trigger Tool
Stock take current QI / safety work & resources
Pilot site for medication safety
Initiate Campaign
Progress Campaign
Agree consistent methodologies:
• Falls• Pressure injuries
• CLABS• Transfers of care• Patient identification
• Consistent regional QI/ Safety work• Implement agreed methodologies• Regional medication safety initiative• Implement outcomes based framework • Identify and progress next improvement priorities
Implement Global Trigger Tool
Implement Global Trigger Tool
Stock take current QI / safety work & resources
Stock take current QI / safety work & resources
Pilot site for medication safetyPilot site for medication safety
Initiate Campaign
Progress Campaign
Agree consistent methodologies:
• Falls• Pressure injuries
• CLABS• Transfers of care• Patient identification
Agree consistent methodologies:
• Falls• Pressure injuries
• CLABS• Transfers of care• Patient identification
CVD & Diabetes high risk patient registers
Cancer therapy wait time improvement
TumourPathway
Bowel screening pilot
Smoking cessation
Implement Region Colonoscopy prioritisation criteria
CVD prevention, screening, assessment initiative• Forecast tool • Primary care assessment and management
Minimise impacts from CVD• Service quality• Wait times• Rehab model
Diabetes prevention, screening, assessment initiative• Get Checked uptake• Retinal screening increase
Develop diabetes pathway
Mentor systems for Diabetes teams • 3 pilot sites • Audit feedback cycle• Links to CVD teams
Engage with Whanau Ora. Support development of Oranga Ki Tuaprogrammes for long term conditions
Implement Clinical Networks: Cardiac, Diabetes, Health of Older People
Promote aging in place• Implement InterRAI• Review home based support services•Transparent and consistent access to ARC
Review causes of ASH admission from ARC
Develop Clinical Pathways for cognitive decline
Bridging information gaps
Increase management plan uptake for CVD patients
Increase management plan uptake for CVD patients
Promote Advanced Care Planning• Engagement and awareness• Education and training• Systems• Roll out to priority groups
Promote Advanced Care Planning• Engagement and awareness• Education and training• Systems• Roll out to priority groups
Whanau Ora• Complete assessments• Increase rate of Whanau with agreed goal oriented plans
Whanau Ora• Complete assessments• Increase rate of Whanau with agreed goal oriented plans
Grow workforce for CVD and DiabetesGrow workforce for CVD and Diabetes
Implement Radiology clinical network• Paediatric radiology• Clinical pathways• Capital investment
Implement Radiology clinical network• Paediatric radiology• Clinical pathways• Capital investmentDevelop long term strategy
for laboratory services Develop long term strategy for laboratory services
Information system priorities• Single PAS• Single clinical workstation • Clinical data repository• Population health data repository• IS infrastructure resilience
Information system priorities• Single PAS• Single clinical workstation • Clinical data repository• Population health data repository• IS infrastructure resilience
Progress development of Regional education, research and innovation initiatives
Progress development of Regional education, research and innovation initiatives
Implementation of effective governance •Supporting clinical leadership•Ensuring delivery of business and clinical plans
Implementation of effective governance •Supporting clinical leadership•Ensuring delivery of business and clinical plans
Life and YearsDo no Harm
Informed Patient
Key EnablersBetter patient engagement
Self management toolsBetter patient engagementSelf management tools
First, Do No Harm
Issues
– We currently harm around 13% of people who enter our hospitals, many from preventable hospital acquired infections and falls.
– Evidence shows that certain interventions, if systematically applied, will save lives, prevent harm to patients, save money, free up capacity and improve productivity.
Actions
• Stock-take current activity• Provide information for baselines• Define terms, methodology,
baseline for : • Falls causing harm• Pressure Injuries• CLABS• Transfers of care• Patient ID
• Medication Safety• Review : 50 most recent deaths• Global Trigger Tool WDHB &
ADHB• Resource Toolkits
FDNH Key Areas
• Falls – reduce harm
• Pressure injuries – reduce harm
• Global trigger tools
• 50 death review
• Medication safety
• Transfer of care
• CLAB - national
FDNH Falls Focus
• Developing an understanding of the issues
• How to do this with a campaign focus
• Initial workshop – early engagement
• Expert group to establish measures:
• Adopted IHI Model for Improvement
• “Collaborative” approach model
Current Data Processes
• Linked to our 3 key aims– Reduction of harm from falls by 20%– Reduction of PI by 20%– Reduction of CLAB by 40% (national project)
• Developed by expert group Acute care and ARRC representation.
What are we trying toaccomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Model for Improvement
Act Plan
Study Do
Langley, et al.
AIM
MEASURES
IDEAS
WILL
IDEAS
EXECUTION
What is a Collaborative?
Brings together groups of practitioners to work in a structured way to improve aspects of the quality of their service.
Involves meetings to learn about:• best practice in the area chosen • quality methods• change ideas • share their experiences of making changes in
local settings. Ovretreit et al. (2002)
•
First, Do No Harm Falls/PI Collaborative
Falls Data
• Review of monthly incident reports
• Agreed operational definitions
• Fall rates per 1000 bed days
• DHBs have provide year worth of base line data
• Ongoing monthly reporting
• (see Regional falls / pressure injuries Agreed operational definitions)
Falls per 1,000 Bed Days
Northern Region
-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
J F M A M J J A S O N D J F M A M
2011 2012
Falls per 1,000 Bed Days
DHB 1
-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
J F M A M J J A S O N D J F M A M
2011 2012
Falls per 1,000 Bed Days
DHB 2
-
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
J F M A M J J A S O N D J F M A M
2011 2012
Falls per 1,000 Bed Days
DHB 3
-
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
J F M A M J J A S O N D J F M A M
2011 2012
Falls per 1,000 Bed Days
DHB 4
-
1.00
2.00
3.00
4.00
5.00
6.00
7.00
J F M A M J J A S O N D J F M A M
2011 2012
Falls with harm per 1,000 Bed Days
Northern Region
-
0.50
1.00
1.50
2.00
2.50
J F M A M J J A S O N D J F M A M
2011 2012
Falls with harm per 1,000 Bed Days
DHB 1
-
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
J F M A M J J A S O N D J F M A M
2011 2012
Falls with harm per 1,000 Bed Days
DHB 2
-
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
J F M A M J J A S O N D J F M A M
2011 2012
Falls with harm per 1,000 Bed Days
DHB 3
-
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
J F M A M J J A S O N D J F M A M
2011 2012
Falls with harm per 1,000 Bed Days
DHB 4
-
0.05
0.10
0.15
0.20
0.25
J F M A M J J A S O N D J F M A M
2011 2012
Falls with major harm per 1,000 Bed Days
Northern Region
-
0.02
0.04
0.06
0.08
0.10
0.12
0.14
J F M A M J J A S O N D J F M A M
2011 2012
Falls with major harm per 1,000 Bed Days
DHB 1
-
0.05
0.10
0.15
0.20
0.25
J F M A M J J A S O N D J F M A M
2011 2012
Falls with major harm per 1,000 Bed Days
DHB 2
-
0.02
0.04
0.06
0.08
0.10
0.12
0.14
0.16
0.18
J F M A M J J A S O N D J F M A M
2011 2012
Falls with major harm per 1,000 Bed Days
DHB 3
-
0.02
0.04
0.06
0.08
0.10
0.12
0.14
0.16
0.18
J F M A M J J A S O N D J F M A M
2011 2012
Falls with major harm per 1,000 Bed Days
DHB 4
-
0.05
0.10
0.15
0.20
0.25
J F M A M J J A S O N D J F M A M
2011 2012
Patients with Pressure Injuries per 100 Patients
Northern Region
-
2.00
4.00
6.00
8.00
10.00
12.00
14.00
J F M A M J J A S O N D J F M A M
2011 2012
Patients with Pressure Injuries per 100 Patients
DHB 1
-
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
J F M A M J J A S O N D J F M A M
2011 2012
Patients with Pressure Injuries per 100 Patients
DHB 2
-
2.00
4.00
6.00
8.00
10.00
12.00
14.00
J F M A M J J A S O N D J F M A M
2011 2012
Patients with Pressure Injuries per 100 Patients
DHB 3
-
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
J F M A M J J A S O N D J F M A M
2011 2012
Patients with Pressure Injuries per 100 Patients
DHB 4
-
5.00
10.00
15.00
20.00
25.00
30.00
J F M A M J J A S O N D J F M A M
2011 2012
Combined data
Falls and PI Learning Session
Monday, June 25, 2012
Version 1
CMDHB / FDNH Falls Driver Diagram
Reduce falls resulting in major harm to 0, with a reduction of 20% by December
2013
Leadership actions to reduce harm from
falls
Front line actions to prevent falls
PRIMARY DRIVERS SECONDARY DRIVERSOUTCOME
Board leadership: establish falls prevention group
Governance and risk leadership: improve analysis and learning
from falls
Train and develop staff in falls prevention
Facilities and estates leadership create a safe environment
Post fall protocols: care and secondary prevention
In-depth assessment and multifaceted care plan
Ask about falls on every admission
Avoid unnecessary hypnotic / sedative medication
Ensure patients have appropriate footwear
Ensure patient can contact HCP when requires assistance with
mobilising
INTERVENTIONS
Fortnightly meetings of falls prevention group, problem solving methodology used.
Ongoing in-depth data analysis, review of common and special cause,
specifically looking at high risk areas
CNE carry out Morse risk assessment training for all ward
staff
Falls risk assessment training and falls prevention included in
orientation of all new staff
Patient Falls - - the immediate management guideline
Falls prevention interventions instigated as per risk matrix
Morse falls assessment completed within 6 hours of
admission
Medication review
Non slip socks
Ensure call bell visible and within reach
Nursing Competency Standards in relation to Morse assessment
and appropriate intervention planning
No. of Patient Falls resulting in SAC 1 & 2 & No. of falls/1000 bed days
No. of Patients with an assessment completed within 6 hours, or reassessed when condition changes
Ordered amounts through Oracle system
Audited by patient safety rounds (Future)
Correct interventions implemented audit
Captured on Onestaff
Yearly audit of SSE (SAC 1 & 2) Falls
Location of falls causing serious harm
Lessons learnt (Don’ts)
• Don’t present it solely a nursing problem!• Don’t judge quality of care on crude falls rates, or panic if there
is an increase in one area over a month or two – falls data can be easily skewed.
• Don’t focus on falls prevention at the expense of autonomy and rehabilitation.
• Don’t panic if falls rates are slow to drop over the first few years – there are no quick fixes for something this complex, and this often represents better reporting.
• Don’t forget real falls prevention interventions are what are what are important – not checklists and “box ticking.”
• Don’t benchmark – especially not serious harm falls!
Northern Region Health PlanFirst, Do No Harm
Dos..• Do get accurate data (not easy!)• Do focus interventions on those at most risk of harm should they fall
(ABC) – Age, Bone density, AntiCoagulation• Do post updates to results regularly and prominently – works best in a
localised manner!• Do build actions into processes that already work – for example
assessment tools into admission packages or care plans. • Do try to be resilient – there are doubters and detractors everywhere.
It would be very easy to give up at times!• Do learn from others, including the doubters and detractors!
www.patientsafetyfirst.nhs.uk
Why Do Collaboratives work?
• Networked community effects
• Effective, horizontal pathways– Supported by the Model– Connected by the Model
• Forms a community (Learning Sessions)
• Reframes a social problem
• Owned by teams/ frontline staff/sectors
What have we learned?• There is limited use of robust improvement
methodology.
• Need to build capacity and capability
• The value of an Improvement Advisor
• The use of measurement for improvement– (few vital measures – dashboard)
• Challenges of gaining and keeping engagement
Going Forward
• Supporting teams during “action” periods
• Further building of capacity and capability
• Improving understanding of value and use of measures
• Facilitate the sharing of learning and resources
• Exploring STOPP /START medication