Rapid Fire Team Presentation Template
Nancy Fletcher, Suzanne Vanderlip and Kelly Stajer
www.saferhealthcarenow.ca
Falls Facilitated Learning Series
Markham Stouffville Hospital
Markham, Ontario
Number of Patients/Clients: 200
www.saferhealthcarenow.ca
Falls Facilitated Learning Series
AIM
“To learn and integrate strategies of sustainability into
our organization’s falls improvement plans to ensure we
increase the likelihood of sustaining practice change for
prevention of falls and injury reduction while holding
the gains over time. We will be active participants in
data submission to SHN Falls Intervention and network
with other enrolled teams in the National Falls
Facilitated Learning Series (FFLS)”
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Falls Facilitated Learning Series
Nancy Fletcher
Suzanne Vanderlip
Toni Britton
Karen Hickman
Doreen Kaneko
Kelly Stajer
Roger Perez
MaryLou James
Team sponsor, Prof.Practice
Team lead, Prof.Practice
Data support
Professional Practice Med
Professional Practice Surg
Professional Practice Peds
Professional Practice ED
Quality and Risk
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Falls Facilitated Learning Series
Change Ideas tested to date
Changes Implemented within Working/Not Working
Organization
Facilitators/Barriers
identified
New falls policy June 2011
Interprofessional &
included clinical and non
clinical staff, MDs &
volunteers
Ongoing education to
continue to sustain
practice and maintain
awareness
Falls Champions (IDHCT)
-New risk assessment tool
-New post falls monitoring
tool with classification of
falls into Type I & Type II
(unwitnessed, bleeding risk &
witnessed & no bleeding risk)
-ID cards made for clinical &
non clinical staff
100% compliance with
completion of falls risk
within 24h of admission
Time frame for post falls
monitoring =37h for Type I
(not completed)
Falls champions
developed a tick sheet
tool that helped prompt
when the next monitoring
was due
Leaf identifiers -client door,
aids, chart, communication
boards
Consistency with all
locations except for spine
of chart
Post falls monitoring
tapered off after 4 – 8h
monitoring
Challenges with
identifying risk client
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when
not on unit eg. DI
Falls Facilitated Learning Series
Type I Fall
Unwitnessed, witnessed
with head injury,
bleeding risk
• Q15mins x4
• Q1h x4
• Q4h x8
• Then as ordered
Type II Fall
Witnessed without head
injury, no bleeding risk
• Q30mins x4
• Q1h x4
• Then as ordered
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Falls Facilitated Learning Series
Change Ideas tested to date
Changes Implemented
within Organization
Working/Not Working
Facilitators/Barriers
identified
Revised audit tool and 10
charts audited each month in
all areas
Currently professional
practice completing
audits need to extend this
to the falls champions
Challenges with accessing
falls champions & tool is a
visual audit of identifiers
& electronic audit
N eurological
E nvironment
A ctivity
T oilet
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Falls Facilitated Learning Series
Change Ideas tested to date
Changes Implemented
within Organization
Working/Not Working
Facilitators/Barriers
identified
Adoption of a specific tool for Similar challenges as
Similar as other adult
obstetrical patients
mentioned previously with population
intra/post partum
other adult population
Adoption of a Pediatric tool
“Humpty Dumpty”
N eurological
E nvironment
A ctivity
T oilet
Similar challenges as with
adult population
Similar to adult
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Falls Facilitated Learning Series
Formula (#Inpt Falls/#Actual Inpt. Days)x1000
Fiscal 2010/2011 and 2011/2012
7
6.1
6
6.1
5.7
5.4
5.1
5
4.8
Falls Rate
4.4
4
3.8
3.3
3
6
4.8
4.1
4.5
4.4
3.8
4.5
4.1
4.5
4
3.4
2.4
2
1
0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
HospWide 2.4 3.3 5.7 6.1 3.8 5.1 4.4 5.4 4.1 4.8 6.1 3.4 4.8 4.5 6 3.8 4.4 4.1 4.5 4 4.5
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Falls Facilitated Learning Series
Lessons Learned on Sustaining Falls
Improvement Work during Action Period
Include all members of the team
• Ensure senior team involved
• Include clinical and non clinical staff
• Include MDs and volunteers
• Engage front line champions
Regular auditing with feedback
Share stories & learn from each other
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Falls Facilitated Learning Series
Challenges to Sustaining Falls Improvement
• Ongoing education on falls prevention
• Continue to use the NEAT acronym but
incorporate into daily work
• Include patient/family in prevention
strategies
• Work on ways to communicate falls risks
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Falls Facilitated Learning Series
Remember to
“Focus on Falls”
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Falls Facilitated Learning Series
Contact Information
Name: Suzanne Vanderlip
Email: svanderlip@msh.on.ca
Phone Number: 905 472-7373 6241
www.saferhealthcarenow.ca