The Power of Patient & Family
Engagement: Falls University
Joanie Ching, RN, MN, CPHQ
Administrative Director Hospital
Quality & Safety
© 2012 Virginia Mason Medical Center
Objectives
• Review our structured learning approach
to patient falls
• Share our progress from measuring
outcomes  reliability of processes
• Highlight patient and family engagement
through delirium work
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
© 2012 Virginia Mason Medical Center
2013 Organizational Goals
Delivering Patient-Centered Coordinated Primary Care
Optimizing Care Transitions
Smoothing Patient Flow
Eliminate Healthcare Associated Infections
Glycemic Control
Prevention of Hospital Associated Delirium
Patient
Vision
To be the Quality Leader
and transform health care
Mission
To improve the health and
well-being of the patients we serve
Respect for People
Values
Teamwork | Integrity | Excellence | Service
Strategies
Integration of the Patient Experience
People
We attract
and develop
the best team
Quality
Service
We relentlessly
pursue the
highest quality
outcomes of care
We create an
extraordinary
patient experience
Innovation
We foster a
culture of learning
and innovation
Virginia Mason Team Medicine Foundational Elements
SM
Strong
Economics
Growth
Realizing the Potential of Our Electronic Health Record
Update the Enterprise Orders & Documentation
Framework
Ambulatory CPOE
Measuring and Improving our Results
Responsible
Governance
Integrated
Information
Systems
Education
Research
Virginia Mason Production System
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
Virginia Mason
Foundation
Stopping the Line: “Falling Star”
What happened?
Every fall
stops the line
• Leadership commits to “drop & run”
• After Action Review
 Staff involved, Patient, Family members
• Every fall → Falls University (founded 3/09)
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Stopping the Line
“… when production stops everyone
is forced to solve the problem
immediately. So team members
have to think, and through
thinking team members grow and
become better team members and
people.”
-- Teruyuki Minoura
Toyota Motors, NA
Prior to Falls University
Director/Manager Pre-work (prior to the Falls University)
Yes No
 Review PSA report
Cerner review






Repeat fall?
Consistency of fall scores?
History of delirium? CAM Score (+ or - )
MAR Review—any meds contributed to the fall, time of
administration?
Fall documentation
Any risk for injury (Age, Bones, Coagulation, Surgery)
 Fall risk precautions in place? Universal? High Risk?
 Bed/chair alarm
 Toileting schedule
 Hourly rounding
 Patient Assignment in Zones
 Hand-off
 RN/PCT integration
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Comment
At Falls University
Discussion at the Falls University (1 minute presentation)
Yes

No
Bring a copy of the PSA report


Give brief patient history
What happened??
(From staff & patient interview)
 Cause(s) of the fall?
(Root cause analysis)
 Nursing foundational elements in place??
(Cell work, Huddle, Handoff , RN/PCT integration)

Were appropriate fall precautions in place?

What could have been done differently?

Type of fall? 1) Accidental (Slip/Trip) 2) Unanticipated
Physiological (Seizure, TIA) 3) Anticipated Physiological



Corrective Action Plans (CAPs)
Degree of CAPs* Me We All
Learnings
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Comment
Falls University:
Results-Oriented Study
Equipment
Fall Prevention
Devices
Fall Prevention
Devices
Family or Support
Members
Family or Support
Members
SCD (Stow and go)
Yellow Fall Prevention
Toolkit
Self-releasing, velcro belts
WE
P
Falls Collab
WE
P
Streifel,
Brune,
Barnes,
Marotta
P
WE
Roles and Responsibilities Heinricher,
O'Connor
WE
Agreements
Heinricher,
O'Connor
WE
Education
Heinricher,
O'Connor
WE
Falls Collab
WE
I
All Mgr/Dir
WE
I
All Mgr/Dir
ME
I
Never alone on commode All Mgr/Dir
ME
M
Family or Support
Members
Staff
Communication
Staff
Communication
Fall Risk Assessment
Toileting
Hourly Rounding
Toileting
Ponischil
Repeat Fallers
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
P
PLAN
PLAN
Observation &
Observe
Develop a
New Vision
and
develop
a new vision
ACT
ACT
DO
DO
AwarenessA Change
In Thinking
Rapid
Implementation
– Give it a try
P
P
CHECK
STUDY
Study the results
© 2012 Virginia Mason Medical Center
Planning
Implementing
Monitoring
Lack of Evidence-Base
“ …in acute hospitals,
no single interventions
are fully supported by
current evidence, and
that multifactorial
interventions may
reduce falls by 1831%.”
Oliver, et al, 2010
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Increasing Patient Surveillance
through Foundational Elements
Geographic assignments
Huddles every shift
In room handoffs
RN:PCT integration
Hourly rounds by caregivers
Documentation near the patient
Daily Leader rounds
People Link Boards updated & staff huddles
monthly
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Unattended Falls: Psycho-social
Root Causes r/t Toileting
1/3: Left alone on
toilet/commode
1/3: Don’t use call light
1/5: slip on way to BR
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
Remainder: trip over clothing,
SCDs or fumble/lose balance
© 2012 Virginia Mason Medical Center
Values Conflict
• Patient autonomy
• Privacy with toileting
• Duty of care to all –vhigh-risk
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Variation
STANDARDIZATION
Improvement
Without standards, there can be no improvement.
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
T
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
13 of 35 points
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Bundle for Highest Risk Group
JH >13 and/or risk of injury (e.g. fracture risk or
bleeding risk)
• Mandatory gait belt
• Mandatory bed and chair alarms**
• Consider low bed and floor mats
• Remain within arms-length of toileting patient
• Level of Assist:
 PARTIAL ASSIST- Keep hands on patient OR
 MAX ASSIST- 2 People + Lift
• Evaluate need for Constant Care Companion
**unless pt has met criteria for alarm discontinuance
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
We told everyone.
We assumed they were all doing the bundle.
How would we know?
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Genchi Genbutsu
•
•
•
•
•
“It’s all lies” unless you see it
Go to where the action is
Look at the process
Know your people and let them know you
Vulnerability is OK
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Fall Prevention Audit Tool
B
Chair Alarm on (green
light on ?)
If NI answered in last 2
columns, were reasons
fully documented?
Bed low and locked
Check bed surface heel
zone
Patient checked for
comfort
Items are within reach
Patient knows time of next
visit (last round crossed off
on board?)
Correct Level-of-Assist Signage
Posted
Gait belt
Y / N
Y / N / NI
Y / N / NI
Y / N
Y/ N
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Presented at Washington State Hospital
Association Safe Table, 2/20/2013
Comments
Bed alarm on (green light
on?)
# of patients with CCC
# of patients on Isolation
precautions
JH score - >13 and history
(pre-screened)
C I T
Ask: toileting Evidence of
toileting (I/O record, Ask
Pt.)
1
2
3
Patient (Last name)
Room #
A
L10
3
Jones 11
2
L14
5
L15
0
L16
2
L17
4
totals
42
4
L9-IMC
5
2
CCU7
15
6
L7 PACE
5
L8
1
0
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
2
L11
L12
1
1
0
0
0
1
9
1
2
2%
21%
2%
5%
1
0
0%
0
5%
0
0%
defect metrics
© 2012 Virginia Mason Medical Center
2
0
1
2
0%
Safety
Comfort
Safety
Comfort
A
B
C
I
T
ED
1
2
2
1
0
1
1
RHU
0
1
2
1
1
0
0
0
3
1
1
7
5
3
17%
12%
7%
Action plan
Toileting
# of times gait belt was absent
Purposeful Rounding
# of times the correct Level-of-Assist
signage was NOT posted
# of times the time of next visit was
unknown
# of times items were NOT within
reach
# of times patient was NOT checked
for comfort
# of times bed surface heel zone was
NOT checked
# of times bed was NOT low and
locked
# of times NI for bed/chair alarm NOT
properly documented
# of times Chair Alarm NOT on
# of times bed alarm NOT on when it
should have been
OCTOBER
# of pts NOT asked about toileting
# of patients with a sitter/CCC
# of pts on precautions
number of patients audited
Unit
But We Told Them to …
Fall Intervention
Strategies
Falls University 201: Delirium
• 10-31% of hospitalized
patients, more likely to occur in
the elderly population
• Falls, functional decline,
extended LOS, nursing home
placement, cognitive deficits &
 mortality
• Constant Care Companions
(CCCs) can provide
supervision
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
“This is not the same
person I’ve known.”
-- A Family Member
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Engaging Family Members
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Ideas from Family Members
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Acute Care of the Elderly PDSA
• A quality improvement efforts to decrease constant care companion
use on two inpatient units
• Focus: Prevention and treatment of delirium
• Education was provided to staff
• Family members invited to participate in care
• Patient rounds with multidisciplinary plan of care review
• Fall rates, CCC use in hrs, and CCC costs were measured before
and after the intervention
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center
Results
• Education was provided to 100% of staff
• CCC use decreased by 4,048 hrs in one
year
• Cost savings over $73,000
• Fall rates and falls with injury ↓
Presented at Washington State Hospital
Association Safe Table, 2/20/2013
© 2012 Virginia Mason Medical Center