Intermountain-led
CMS Hospital Engagement Network
Falls Prevention
October 10, 2014
Affinity Call
Marlyn Conti, BSN, MM, CPHQ
Patient Safety Initiatives Manager
Intermountain Healthcare Quality and Patient Safety
Jason Scott, MPH, MPP
Carlos Barbagelata, MS
Outline for Discussion
•
•
•
•
•
Review of data through Q2 2014
‘High performers’ – Identify and ask what they are doing?
Falls recommended metrics
“Just-one-thing” – updated document
2014/15 plans
• Reach out to low performers to provide assistance
• Continue Webinars for sharing?
• 2015?
Overall Progress Through Q1 2014
Overall Progress Through Q2 2014
Intermountain HEN 2012- Q2 2014
submitting Inpatient Falls with Injury
High Performing Benchmark: 0.50
Intermountain HEN 2012- Q1 2014
submitting Inpatient Falls with Injury
Intermountain HEN 2012-Q1 2014
submitting Hospitals Inpatient Falls
High Performing Benchmark: 2.15
Intermountain HEN 2012-13
submitting Hospitals Inpatient Falls
HEN Falls Measures
• Metric specification resource manual
http://www.henlearner.org/wpcontent/uploads/2012/03/HEN_measure_Feb5.pdf
• Submission schedule:
• Nov 20, 2014: for data through August 2014
HEN Falls Measures
Inpatient Falls
HEN Falls Measures
Falls with Injury
High Performing Hospital Highlight…
Most Improvement
Inpatient Falls
Most Improvement
Lowest Rates
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
HEBER VALLEY MEDICAL CENTER
MENLO PARK SURGICAL HOSPITAL
DELTA COMMUNITY MEDICAL CENTER
OREM COMMUNITY HOSPITAL
AMERICAN FORK HOSPITAL
BAYLOR REGIONAL MEDICAL CENTER AT
GRAPEVINE
HEBER VALLEY MEDICAL CENTER
SUTTER COAST HOSPITAL
GARFIELD MEMORIAL HOSPITAL
BAYLOR REGIONAL MEDICAL CENTER AT
GRAPEVINE
SUTTER MATERNITY & SURGERY CENTER OF
SANTA CRUZ
CASSIA REGIONAL MEDICAL CENTER
EDEN MEDICAL CENTER
ESPANOLA HOSPITAL
PROVIDENCE HOOD RIVER MEMORIAL
HOSPITAL
DELTA COMMUNITY MEDICAL CENTER
AMERICAN FORK HOSPITAL
BAYLOR MEDICAL CENTER AT WAXAHACHIE
High Performing Hospital Highlight…
Most Improvement
Inpatient Falls with Injury
Most Improvement
Lowest Rates
BAYLOR HEART AND VASCULAR HOSPITAL
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
DELTA COMMUNITY MEDICAL CENTER
THE HEART HOSPITAL BAYLOR PLANO
AMERICAN FORK HOSPITAL
PROVIDENCE MEDFORD MEDICAL CENTER
PROVIDENCE NEWBERG MEDICAL CENTER
BAYLOR MEDICAL CENTER AT CARROLLTON
PROVIDENCE MEDFORD MEDICAL CENTER
SUTTER SOLANO MEDICAL CENTER
SUTTER COAST HOSPITAL
BAYLOR MEDICAL CENTER AT WAXAHACHIE
UPPER CONNECTICUT VALLEY HOSPITAL
SUTTER SOLANO MEDICAL CENTER
SUTTER DAVIS HOSPITAL
SUTTER MATERNITY & SURGERY CENTER OF SANTA
CRUZ
SUTTER DAVIS HOSPITAL
AMERICAN FORK HOSPITAL
Just One Thing Matrix
Recommendations
Getting Started
Working Harder
Ahead of the Curve
Implement standard
Assessment tools,
protocols and prevention
strategies
Appoint “leads” to drive
improvement & identify
or champion teams that
includes unit level
nursing, quality, patient
safety, physical therapy
and pharmacy services.
(high level of evidence)
Implement decision
algorithms and/or
computerized decision
support in the electronic
medical record to target
interventions based on
patient specific risk
factors
(high level of evidence)
Getting Started and Keeping it going!
• Set Organizational priority
• Identify Risks and Gaps
• Develop Monitoring Systems
• Designate Champions
• Integrated Nurse Charting and Care Plans
• Repeat Cycles of ‘Plan-Do-study-Act’
Falls Bundle &
Falls Survey Report
Falls Bundle
• Measurement
• Inpatient falls rate
• Falls/Patient Days
• Fall-related injuries/patient days
• CMS Hospital Acquired Conditions (HAC) rates
• Assisted vs unassisted falls
• Assessment & Reassessment
• Standard risk assessment tool (standardized across all care
settings)
• Policy for timing of assessment
• Reassess when condition changes and after procedures
Falls Bundle
• Interventions
• Signage
• Door frame magnet/Door signs
• Patient/Family Education
• Standard FAQ sheet
• Room environment
• Bed low, room free of clutter, side rails up, bed alarms on
• Visibility
• Made reminders larger and brighter (yellow blankets, slippers, etc)
• Fall prevention protocol recorded in medical record
• Hourly rounding made part of falls protocol
• Safe Patient Handling (no lift) policy
Falls Bundle
• Patient Family Education
• Standardized education content
• Available as applicable just-in-time), online, etc
• Validation that learning has occurred such as a teach-back
concept or skills pass-off.
• Staff Education & Learning
• Standardized education contend on hire
• Annual skills fairs
• Annual assigned learning modules
• Leadership/Structure
•
•
•
•
Fall prevention team
Integration with quality and patient safety plan and structure
Unit level & hospital level Fall Prevention champions
Post fall huddles and fall evaluation/questionnaire
Falls Bundle
• Equipment
• Beds
• Standard models where possible, reduces learning needs and
maintenance issues
• Bed Alarms
• Integrated with nurse call systems when possible
• Lifting Equipment
• Available and in use (portable, overhead, and transfer such as gait
belts, slider sheets/boards, etc.)
• Nurse Call System
• Integrated with beds and/or communication devices
• Environmental Safety
• Electrical outlets, lips on doorways
Falls Survey Results
1. What facility are you from?
17 Facilities Responding
Baylor
Baylor Scott & White Hillcrest Medical Center - Waco Texas
Dr. Dan C. Trigg Memorial Hospital
Intermountain Medical Center
Intermountain SWR
Mayo Clinic Health System - Franciscan Healthcare
Mayo Clinic Health System - Northland
McKay Dee
Presbyterian Ph-Main campus
Primary Children's Hospital
Providence St. VIncent Medical Center
Regions Hospital, St. Paul, Minnesota
Riverton
Sanpete Valley Hospital
Sutter Medical Center Santa Rosa, Ca
Upper Connecticut Valley Hospital
VVMC
2. What is your role at your facility?
Answer
Response
%
Quality
11
44%
Nursing
10
40%
Other (Specify)
4
16%
Education
0
0%
Total
25
100%
Other (Specify)
Patient Safety
Nursing Quality
Patient Safety
Nurse Manager
3. What is the size of your facility?
Answer
Response
%
>200 people
19
73%
100 - 200 people
4
15%
20 - 49 people
3
12%
50 - 99 people
0
0%
Total
26
100%
4. Does your facility have a leadership-appointed fall prevention
team assigned to work on fall prevention?
Answer
Response
%
Yes
23
88%
No
3
12%
Total
26
100%
4a. Is your fall prevention team multidisciplinary? (if yes, which
disciplines are included?)
Answer
Response
%
Yes
19
86%
No
3
14%
Total
22
100%
Yes
PT, Pharmacy, Risk, Dietary
nursing, PT/OT, patient safety, facility safety and security, occupational health, physicians
nursing, PT/OT, Security, Education, IT, Radiology, Quality
Rehab, Transportation, Environmental Services, Lab, Nutrition
Safety officer, lift team, Nursing (bedside, managers and directors), Risk and quality members
Nursing (Med/Surg, OR, Mental Health, ICU, Acute Rehab, ED), Pharmacy, Physical Therapy, Nursing
Education, Patient Safety,
nursing, PT, OT, pharmacy, resp, lab, physicans, Social work, and case management.
Managemet, OT/PT, Pharmacy, Quality, Nursing
PT, Pharmacy, employee health
Nursing, PT, Imaging, Patient Relations, Security, Quality, Risk
Nursing, Radiology, Lab, all outpatient areas, Risk, Quality,
4b. How frequently does your fall prevention team meet? (Check
all that apply)
Answer
Response
%
Once a Month
15
65%
2-3 Times a Month
0
0%
Once a Week
0
0%
Other (e.g as-needed,
etc.)
8
35%
Other (e.g as-needed, etc.)
Quarterly or more often as needed
Have been once a month, now quarterly
As-needed
5. What standard risk assessment tool do you use?
Answer
Response
%
Other
11
48%
Morse
7
30%
Hendrick
4
17%
Hybrid Tool
2
9%
Schmidt
0
0%
Other
Developed own
EPIC
Moving to Morse soon
Combination of morse and our tool
Johns Hopkins
Unsure
Tandem
Intermountain tool
Humpty-Dumpty in near future
6. Do you have bed exit alarms integrated with the nurse'scall
system?
Answer
Response
%
Yes
18
69%
No
8
31%
Total
26
100%
7. Do you use a patient contract for falls risks?
Answer
Response
%
No
24
92%
Yes
2
8%
Total
26
100%
8. What tools do you use to educate patients/families about fall
prevention? (check all that apply)
Answer
Response
%
Fact Sheets
18
75%
Online materials
7
29%
Other (specify)
12
50%
Other (specify)
Teaching by RN's and staff
Verbal teaching regarding falls risk and interventions
Verbal Education
Teaching sheets
Handout and verbal communication
Whiteboards reminders,
Discussion
Face-to-face discussion
Communication board, unit orientation, rounding
In-room white boards
9. What tools do you use to educate staff about fall prevention?
(check all that apply)
Answer
Response
%
Posters
19
76%
Fact Sheets
16
64%
Assigned Computer-Based Training
23
92%
Other
11
44%
Other
Annual fall prevention workshop and online training
Staff meetings
Unit Based Falls Champion
Shared Decision Making
Staff meeting, post fall assessments, and review of cases
Orientation checklists
Post falls huddle, annual skills day
Huddles, staff meetings, Metric Boards
1:1, unit fall champions, newsletter articles
10. With what frequency do you assign staff education? (Check
all that apply).
Answer
Response
%
Annual
23
88%
As-Needed
16
62%
On Hire
11
42%
Other (Specify)
3
12%
Every Other Year
0
0%
11. Do you provide patient fall incidentevent reports for use by
hospital staff managers and teams? (If yes, please describe how
reports are distributed or made available).
Answer
Response
%
Yes
23
88%
No
3
12%
Total
26
100%
11. Do you provide patient fall incident event reports for use by
hospital staff managers and teams? (If yes, please describe how
reports are distributed or made available).
Other
Via email to unit managers and designated staff leaders
Available via reporting system
Staff meetings, Electronic Event System
Information is discussed at meetings with leaders and at staff meetings. Patient information and
outcomes are shared but never posted. Data about falls is posted in the nursing units
Reports are viewed and managed at a local level of the location of the fall. Falls Prevention team analyzes
the data from the reports to identify house-wide trends.
Event reports are filled out online and can be accessed by managers and quality improvement staff. Postfall assessment are filled out and scanned to management, and falls committee representative
Fall with injury reports are sent to unit managers post-fall debrief. Statistic reports are available via STATIT
and a monthly report is shared to nursing managers at the monthly fall team meeting.
Data from risk, collected by Quality, shared with staff, managers, leadership, governing board, and medical
staff.
Shared with managers who, in turn, educate and follow up with staff. Stats are shared with managers and
staff.
Fall reports for hospital and per units with monthly rate and rolling 6 month rate, also have fall prevention
bundle audit data
12. What is the most successful approach that you feel has
contributed to reducing patient falls?
Text Response
Getting staff involved in assessing their own unit readiness to prevent falls. Making it a goal with incentives for
completion. Telling stories about falls and near misses. Integrating fall prevention with safe patient handling.
The visuals applied: This helps all staff identify which patients are high risk falls.(i.e) Gait belts hanging on door
frame, red booties on falls risk patients,bedside reporting also helps remind patient and family members.
Proper equipment, staff training, frequent reminder of importance, keeping it in the forefront at all times
Change in culture - falls are not expected or a natual part of being hospitalized.
Constant vigilance; staff accountability; manager engagement; unit-based champions; current data - metrics;
Falls prevalence monthly, multildisciplinary approach and the increase in lift equipment and the use of a lift
team. Staff awareness, daily huddle focus, and education
Root Cause and Common Cause Analysis with Direct Feedback to Staff, Units, Ministries.
Assessment tools that identify high risk patients, bed alarms, chair alarms, pt's are designated as a falls risk on
patient census board, and fall magnets are placed outside doors. If a fall occurs we do post fall assessment and
identify any contributing factors and or trends. Partnering with family/caregivers to team up to prevent falls.
Making our team multidisciplinary, Fall contracts and hourly rounding addressing the 4 Ps
Bed alarms connected to call system. awareness when falls occur what the reasons were reported to quality
and patient safety committee. clinical ladder RN project for 2014
Currently piloting. No One Walks Alone program. We got our infromation from Kaiser San Diego. Pilot has just
begun but has provided data that it may have a profound impact on our overall fall rate.
Repeat falls reduced by standardizing the interventions once a patient fell and the use of alarms to prevent falls
Required monthly audits done by each unit to ensure our falls prevention strategies are in place - magnets,
stickers, gait belts, bed alarms, white boards, risk scores etc.
13. To help us measure progress, please indicate your facility's program
status since starting the HEN collaboration to reduce patient falls.
A. "Getting Started": This level consists of implementing standard assessment
tools, protocols and prevention strategies.
B. "Working Harder": This level focuses on appointing "leads" to drive
improvement and identify SWOT (or champion) teams that includes unit nurse.
C. "Ahead of the Curve": This level focuses on implementing decision algorithms
and/or computerized decision support in the EMR based on patient risk
factors.
What level do you feel your facility is at?
Answer
Response
%
Getting Started
6
24%
Working Harder
10
40%
Ahead of the Curve
9
36%
Total
25
100%
14. What barriers are you experiencing that are preventing you fromachieving
your goals to reduce patient falls?
Fall Prevention Barriers
Enough bandwidth to keep up the focus. Time, consensus, conflicting priorities.
Staff shortages. Patient acuity and volume. Buy in from unit managers and their staff
High falls risk patients inability to remember they can not ambulate on there own."Patients cognitive level"
Equipment issues, Many changes in workflow. Accountability issues.
Multiple competing priorities that seem to switch the focus away from fall prevention; increasing Nurse Patient
Ratios; staff turnover;
Consistency in standard implementation -- variability amoung staff performance.
Dementia patients who can not find SNF placement related to behavior--longer stays increase risk
Staff engagement with the process. Hospital does not bed alarms on every bed and alarms are not routed to
the nurse call system.
Staff perception with nursing ratios increasing is the hardest thing.
There are certain things that are outside of our control no matter how hard we work and no matter what
interventions we put into place! It's very frustrating..
Have been able to work through barriers. Zero falls with moderate or severe injury in 698 days (since we began
monitoring in Nov 2012.
100% of staff staying in bathroom with patient and not "turning to get something outside of the bathroom"
Consistently remembering bed alarms
In children, falls don't usually cause expensive harm or injury as in adults, so leadership often overlooks the
importance of fall prevention as a proactive process.
Final Thoughts
• 1. What changes have you made since joining the
HEN to reduce falls?
• 2. What have you done to recognize achievements in
fall reduction?