Falls Virtual Learning Session # 4 &
Closing Congress Team Rapid Fire
Presentation Template
Cross Cancer Institute, Edmonton, Alberta
Amy Kantor, Quality Consultant
Join the Falls Prevention Virtual Learning Collaborative
Who We Are
Edmonton, Alberta
Ambulatory and Inpatient Care
• 3 inpatient units
• ~56 beds
• ~140 RN’s plus NA’s, PT, OT, RT, Pharmacists and
MD’s
Primary Cancer Care facility, serving all of northern Alberta.
Team Members
Team Member
Role
Nadia Kloc
Inpatient Nurse Manager
Carolyn Howe-Riddell
Inpatient Resources Nurse
Carole Szwajkowski
Nursing Education
Judy Poon
Rehab Medicine,
Physiotherapy
Amy Kantor
Quality Consultant
AIM
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.
•
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.
Scope: Inpatient units (3 units, 56 beds)
Change Ideas
Changes tested during Falls VLC PDSA Cycles:
Implementation of an appropriate Assessment Tool
• Initially used Schmidt tool, now working with Morse tool
Inventory of mobilization equipment and aids and storage locations
• Discovered shortage of transfer belts, purchasing more and moving to a more
visible and accessible storage location
Evaluate location of majority of falls (~60% occur in the bathroom)
• Planning to trial bathroom signs encouraging patients to call for assistance
Implementation of a Post-Falls Assessment Tool
• Trialing and revising a tool to help discover specific reasons for falling
Implement an apple as a symbol for a patient at risk of falling
• To be placed outside of patients room, used for recognition and promotional
‘materials’
Measures
1: Falls Rate per 1000 Patient Days
5.00
4.50
4.00
Implemented Risk Assessment
Falls/1000 days
3.50
3.00
Change in Event Reporting System
2.50
2.00
1.50
Number of Falls per Month
Range: 4-7
1.00
Mean: 5
0.50
0.00
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
Fall Rate
4.74
3.71
3.29
3.90
4.46
2.00
3.29
2.58
2.76
2.48
3.00
Goal
2.40
2.40
2.40
2.40
2.40
2.40
2.40
2.40
2.40
2.40
2.40
Month
Measures
Percentage of Falls Causing Injury
90.0%
Implemented Risk Assessment
80.0%
Change in Event Reporting System
Percentage of Harmful Falls
70.0%
60.0%
50.0%
40.0%
Number of Falls Causing
Injury per Month
30.0%
Range: 0-4
20.0%
Mean: 2
10.0%
0.0%
Apr
2010
May
2010
Jun
2010
Jul
2010
Aug
2010
Sep
2010
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
CCI Data
14.3%
33.3%
Goal
19.0%
19.0%
60.0%
0.0%
42.9%
60.0%
80.0%
25.0%
50.0%
50.0%
50.0%
19.0%
19.0%
19.0%
19.0%
19.0%
19.0%
19.0%
19.0%
19.0%
Month
Measures
Percentage of Completed Fall Risk Assessment on Admission
120.0%
100.0%
Percentage
80.0%
60.0%
Number of Charts
Reviewed per Month
40.0%
Range: 54-82
Mean: 67
20.0%
0.0%
Oct
2010
Nov
2010
Dec
2010
Jan
2011
Feb
2011
CCI Data
66.2%
81.7%
83.3%
82.4%
87.5%
Goal
100%
100%
100%
100%
100%
Month
Lessons Learned
Lessons Learned/Key Insights
Slow and steady wins the race
Buy in from staff is essential to success
Important to understand the foundation of the concept first
The right tool is needed: take the time to find it, don’t be afraid to change it
Follow through is required and it needs to be consistent
Ongoing compliance monitoring is key to maintaining gains
Changes to our event reporting system just prior to implementation may
have affected our data
We’re still learning!
Quick Wins
• Champions emerged from Physiotherapy department
 Data collection became easy with their help
• SHN Virtual Learning Series taught the team about:
 Quality improvement methodology (Can be applied to other projects)
 Data collection, analysis and trending
 Viewing the issue from a broader perspective: i.e. pharmacology,
special considerations for the elderly, etc.
• Great connections made between departments
(Nursing, Education, Physiotherapy, Quality)
• Great ideas to build on from other teams in the collaborative
Next Steps
Key Sustainability Steps/Plan:
Target Dates
Decide on an assessment tool
1 month
Implement bathroom signs
1 month
Finalize post falls assessment tool
and decide if it is going to be used
Next 2 months
Roll out education to the staff (serve 1 month
apple treats to generate recognition)
Launch the apple symbol
1 month
Contact Information
Amy Kantor
Amy.Kantor@albertahealthservices.ca
780-989-5954
Judy Poon
Judy.Poon@albertahealthservices.ca
780-432-8841