National Falls Facilitated Learning Series
Team Improvement Charter November 2011
Project Name:
Team Members:
Team Lead:
Team Sponsor:
National FFLS Learning Series
Elaine Ferguson (PT), Ophelia Leung (OT), Cathy Wunderlich
(RN), Melissa Crozier (RN), Aimee Bourgoin (RN)
Aimee Bourgoin
Averil Suriyakumaran EG Site
Purpose of Falls Intervention Team:
To work on strategies to sustain the falls initiative in order to continue this
organization’s commitment to Falls improvement. We want continue to prevent
falls and create a safe environment for our residents, minimizing the use of
restraints. To this end, we will submit our data to the FFLS as well as make our
staff at the facility aware of the initiatives we are undertaking to sustain the Fall
Initiative for Covenant Health at the EG site.
Scope and Boundaries:
Team members involved had been part of the previous falls initiative to a greater
or lesser extent with residents at EG. The target will continue to be residents at
risk for falls and injury at the site. Sustainability strategies will be for improving
on the gains made from the previous strategy and embedding best practices for
fall prevention and injury reduction into the site culture.
Improvement Aim:
To engage in fall prevention and injury reduction as team members working with
the National FFLS to learn strategies and plan for sustained improvement
reducing falls and injury from falls.
By March 2012:
 Develop a plan for Falls Prevention and Injury Reduction for sustaining
practice change.
 Collect and submit data monthly on measures to Safer Healthcare Now!
(SHN) in order to use data to monitor and facilitate sustained
improvements.
 Demonstrate a 15% improvement in baseline measures and sustain them
for 3 consecutive months.
Measures for our healthcare setting:
Long Term Care Measures
Current Performance
Goals
1. Percentage of falls causing
injury.
13.21 %
2. Percentage of residents with
completed fall risk assessment
on admission.
93.3%
100%
3. Percentage of “at risk” residents
with documented falls prevention/
injury reduction plan.
73.3%
100%
4. Fall rate per 1000 resident days.
117.78
5. Percentage of residents with
completed fall risk assessment
following a fall or significant change
in medical status.
6. Percentage of residents with restraints
in place.
0%
25%
11%
(reduce by 15%)
100.18
(reduce by 15%)
100%
21%
(reduce by 15%)
What Changes Will We Make?
We determined that we need to reassess the risk piece of past practice in
order to have staff place the priority on those residents at greatest risk of
falling. That is, our past practice was to place a leaf outside the door of all
residents who were at risk of falling. That usually meant that a number of
residents on a unit were identified. What we will do now is target new
admissions during a vulnerable initial two week period and also any actual
fallers. We are wanting to revamp our existing Green Leaf program and
extend it to be not just “ASK 3” but for our population, “What else?” before
staff leave the room. After several years of use, we realize our screening tool
also needs revamping so that interventions co-exist with the screen and so
that we follow-up with those residents who have a change in their medical
status using MDS. We want to change our staff orientation to include the
revamped screening tool and revised Green Leaf program. We want to
empower HCAs to give us feedback on interventions that we trial, including
the screening tool and the Green Leaf program changes. We feel that report
time is a critical time to talk about the risky fallers and so we will target and
demonstrate that behavior as we go to the units. We will try to advocate for
some system changes that can make a difference, for example a new call bell
system in the older part of our building which would allow us to use
bed/charm alarms more effectively. Our quality improvement statistics are
not being reviewed and the information passed along to staff so that they see
how the initiatives are working or not. We want to communicate our fall
rates to staff so that they are part of the initiative. We will work with new
managers to make them aware of how to review critical incidents, most of
those relate to falls.
How Will We Manage the Improvement Project?
 Demonstrate mutual respect, seek out and listen to other team
member’s perspectives.
 Hold regular meetings with minutes prepared.
 Have a communication plan to reflect issues, discussion points, action
steps and responsibilities.
 Share the workload.
 Include other interested partners that we identify.
 Share successes with each other, the site and the organization.
 Start small with our PDSA cycles and bite off manageable pieces, unit by
unit if necessary.
 Connect and consult with FFLS Faculty through scheduled team calls.
Team Roles and Responsibilities:
Team Sponsor
 Will ensure that our strategies are aligned and embedded in the site
and organization strategic objectives.
 Provide resources in terms of clerical support and allow team
members to participate in activities as a priority.
 Establish a reporting mechanism within the site whether through
meetings or a site newsletter.
Team Leader
 Complete and share team charter in a manner that ensures support
of team members.
 Organize and lead effective meetings, maintaining records and
improvement data.
 Serve as the communication link between the team and the team
sponsor.
 Ensure that data is collected and submitted consistently to FFLS.
Team Members
 Share practice and care knowledge, skill and experience.
 Communicate and develop a shared understanding within the team
of the work necessary to sustain the change in falls prevention and
injury reduction for our residents.
 Use PDSA cycles to define next changes and to test them.
 Lead and support coworkers to adapt to new processes.
 Complete tasks and assignments within and between meetings.