Using The Model For Improvement To Reduce Falls and Injury · First Do No Harm ( PDSA) Health Quality and Safety Commission National Patient Safety Campaign Institute of Healthcare
17
Falls Preceptors - Physiotherapist, Mobility Therapist, OT/Activities Therapist, Health Care Assistants Manager: Helen Delmonte, Coordinator: Catherine Heaney Our Team A real journey Using The Model For Improvement To Reduce Falls and Injury
Falls Preceptors - Physiotherapist, Mobility Therapist, OT/Activities Therapist, Health Care Assistants
Manager: Helen Delmonte, Coordinator: Catherine HeaneyOur Team
A real journey
Using The Model For Improvement
To Reduce Falls and Injury
What we had established Before First Do No Harm
Policies and Procedures
Various Interventions
Auditing “keeping” data
BUT....
Standing
High Numberof Falls
Goal = reduce fallsNo Standardised Process
for enablingsustained change
No Collaboration
New interventions and audits TIME+ EFFORT = gains Difficulty in truly
understanding andfixing problems
Presenter
Presentation Notes
- High Number of falls – Our goal of course was to reduce falls, though it was a general one, we hadn’t actually decided on our goal percentage decrease or decided on any time frames. The Gains made did not reflect the Large amount of time + effort put into new interventions and audits We could see that there were some interventions which weren’t working 100% and although we could had some answers as to why and other “hunches” we didn’t have a method for truly understanding a problem or fixing it effectively and quickly. We had no standardised process for change – so effectively we felt like we were standing still And with little collaboration with other facilities, as much as we tried to get creative we were still really thinking inside the box
First Do No Harm ( PDSA)
Health Quality and Safety Commission
National Patient Safety Campaign
Institute of Healthcare Improvement Model (IHI)
Management said “Go for It, we are with you”
Presenter
Presentation Notes
Helen Delmonte joined the Auckland District Falls subgroup, and we became a cluster host, assisting to determine common definitions and practices We downloaded the IHI Improvement model in preparation for attending our first Learning Session We came to learn more about the involvement of the National Patient Safety Campaign
We stepped into a whole new world!
Driver Diagrams
The Model of Improvement
Outcome Measures!
Direction and Practical Method
PDSA Cycles
Presenter
Presentation Notes
We were introduced to Driver Diagrams and Outcome measure tables. When we learnt about the PDSA cycle method and realised that quality data and gains can be made with very small scale intervention trials and audits. That for us was like a light had suddenly turned on and we were really motivated and excited to try it.
Creating the culture for change – Spark of Life “Shift your focus”Development of Fall prevention charter, driver diagram
Participation in Learning sessions, ADHB subgroup, Cluster group host
Reduce Falls, and Falls with Harm by 20% from Jan 2012 to Dec 2013 ( in alignment with FDNH goals)
1st Steps
Improve resident wellbeing, safety and overall quality of life
Further develop and strengthen our program – Pursuit of Excellence
Presenter
Presentation Notes
Creating the Culture – At Mercy Parklands we have Dementia Care Programme called the Spark of Life. The relevance of this at that stage was that to effectively implement the Spark of Life Programme, the literature talks about the need to create a culture change facility wide to the Spark of Life way of thinking. I think for us, this acted as a bit of a platform as the staff had already been part of being faced with the challenge to receive a new way of thinking. The other very important step that helped us at this initital stage is the Spark of Life’s Principle of needing to “Shift your focus”. We translating this principle into our Falls Prevention programme and challenged staff to shift their focus or beliefs of falls. Where some may think that falls are just a part of life and inevitable for people who are elderly, we worked to adopt a new belief, that falls are in fact preventable and people who are elderly can continue to live active lives. Participation in the First Do No Harm Learning session series gave us the understanding and tools to develop the necessary documents for our change package
Presenter
Presentation Notes
The driver diagram really helped us to see how our current interventions were driving us towards our goals. It also gave us some perspective in seeing that some of the interventions that we using were actually still really in the ideas and trial stage and we had a lot more work to do before we could consider these to be established intervention.�Initial Driver Diagram completed in July 2012. Updated in April 2013 with some of the creative ideas moved to implementation and new creative ideas added
Developing measures that reflect improvement
Making change to our systems to create and sustain improvement
Outcome Measure ChartRun and control charts practiced
Dashboard developed Use of Plan Do Study Act (PDSA)
cycles
Next Steps
Outcome Measure TableTool for audits
Method foreffectively
communicating Feedback
to staff
Presenter
Presentation Notes
The outcome measure chart challenged us to be very specific about what we considered a quality indicator and to put practical methods in place for collecting and feeding back data findings. Peter Leong took the time to look over our draft to ensure we were on the right track which was very helpful to us. �We decided to use the tool you can see here. Four of us are each given a form and allocated a day and shift. This means that we are gathering the information across all shifts, all areas and weekend and week days but essentially each of us only have to spend a collective time of about 20minutes on this audit per month. The information is then translated into the “Blue is Best Chart” and this is what we use to help feedback our performance and progress to staff.
Presenter
Presentation Notes
Prior to our development of a dashboard we only used the monthly fall incident numbers to help guide our knowledge and practice. Introduction of the run charts together with knowledge of the 4 rules that indicate a change may be taking place – Shift, Trend, Run, Astronomical values, has helped us distinguish between natural variation in our data, the need to intervene to make a change, and actual sustained improvements.
Creative Ideas
Use of evidence based practice
High falls risk profile developmentProactive( intentional) rounding
Staff engagement – education, results feedback, team development
Resident/family engagement – awareness posters, info brochures
Leadership expertise and knowledgeDevelopment of “ home environment” wing
Skipping along
High Fall risk Profiling
An example Implementation
and result
Presenter
Presentation Notes
Mrs D was one of the residents to receive a high fall risk profile. �When she was first admitted, she had serial falls, 8 in fact, while various interventions which appeared appropriate were put in place. �In August, she received a falls profile which highlighted the trends and nature of her falls.�Using this method, her care could be further individualised and she was then falls free for the following 11 months. A study was carried out for the profile looking at the comparison of falls rate 2months prior to and 2 months following the implementation of a fall profile. A 48% decrease in falls rate was seen.
PDSA Mapping tree for High Fall Risk Profile
Family Engagement
Education of falls prevention
strategies
Information on protecting
independence with Hip
protectors
Falls prevention wear/equipment
On going support through
partnership
EngagementStaff
Preceptor Training for
the passionate
Formal and informal
staff training
Feedback on
process measure results
Reflective Exercises
with staff when
quality falls short
Rewards,Thanks(cake!)for
efforts
Staff interviews
to gain their perspective
/ideas
Presenter
Presentation Notes
In a residential facility there is a structure much like an iceberg. The planners and diagram makers make up just the tip! It is the Health Care Assistants who make up the mass of the iceberg or structure and that is why no change will occur without staff engagement. We aim to engage our staff in each part of the process. We train and inform to empower them with knowledge, They participate interviews so we may gain perspective from those on the frontline on what they think needs change and could work, we enable transparency of progress through regular feedback, we invite them to reflect on incidents where quality has fallen short to enable future success And we reward that success!
Oct 2012 ‐
we commented on the Cluster Group model for the First Do No Harm
website
Walking Together –
Sharing our knowledge
March 2013 ‐
Mercy Parklands were asked to participate in the Health Quality and
Safety Commission educational videos for the National Patient Safety Campaign Launch
November 2012 ‐
Helen Delmonte presented at the FDNH 2nd
Learning session on a Falls
prevention program from an Aged Care Facility perspective
Jan 2012 ‐
Helen Delmonte joined the Auckland District Falls subgroup, and
became a cluster host, assisting to determine common definitions and
practices
Presenter
Presentation Notes
We continue to be part of the collaborative, participating in the 2 monthly subgroup meetings and responsibility as a cluster host Our presentation from the Learning session is available on the FDNH website for others to share our learning We attended the National Patient Safety launch – Open for Better Care - on 17th May and saw the “Directors Cut” of the video made at our facility, we are looking forward to sharing the completed video with our residents and staff that took part, and knowing that it will be used to help others in similar facilities
Since 2009 there has been a decrease in fall incidence every year with an overall
percentage decrease of 45.05%.
In four years the incidence of falls has nearly been halved and continues a downward
shift demonstrating sustainability of our program.
Our largest percentage decrease from one year to the next was in
line with when we
started the collaborative process with First Do No Harm and the
implementation of
an effective methodology by which to operate. – a 29.17% decrease.
Between 2010 and 2011 we achieved a 36.4% decrease in Falls with
fractures down
from 11 to 7.
In 2012 a total of 8 falls with fracture occurred , with only 3 falls with fractures
occurring so far in 2013, demonstrating that our focus on injury
prevention is being
sustained and effective.
Sustain
our Continuous Improvement in Falls reduction with the focus on reducing Harm
from Falls utilising the IHI improvement methodologyAchieve
Outstanding Achievement rating in our next Equip 4 Survey(OA ‐the organisation
is recognised as a leader in the area of Falls prevention and management)Learn
from others and continue on this journey
Quantum Leaps
Presenter
Presentation Notes
The average hospital costs for a person with a hip fracture are $26,000 , plus associated loss of independence and decreased quality of life, and significantly increased risk of mortality. Knowing that we are helping to save these costs and reduce the adverse consequences for our residents is empowering
Last Thoughts and Tips
Project Charter and Driver Diagram
Goal Setting
Outcome Measure Table and Practical
methods for measurement
Tracking data that tells a story – run
charts, control graphs etc.
PDSA Cycles
‐
Think small length and sample
‐
Think big number of variables you test it
under.
Presenter
Presentation Notes
Last slide on the presentation to do a summing up slide - tips, last thoughts - The main advice we would like to share from our journey of lerning which is still ongoing... - establish your driver diagram and outcome measure table and decide on a practical method for ensuring that you are actively using these documents. Attend the educational session for tracking data because this will be an eye opener to all staff in how you have been progressing, knowing when to take section for fluctuations and it is admittedly ridicullously exciting to see that little median line start to drop, PDSA - keep it small.
