PDSA Cycle Used for Advanced Falls Prevention MSH Charter

Project Name: Fall Prevention * this project was approved as part of the Quality Safety Plan in Aug 2010 Overall Timeline: 12 – 18 Months Updated Dec 2011 Exec Lead: Carole Moore Project Lead:Mary Lou James Physician Lead:Dr. D. Austin

C Background and Context: 2. Project Objective and Scope. Performance measures related to quality, safety, Baseline Sept Oct Nov Dec o

r 1. 2 serious falls in Fall 2010 / Spring 2012 has resulted To: cost & others 2011 2011 2011 2011 e

T complete revision of the fall prevention policy in MSHC and -decrease the the # of fall incidents per 1. Decrease falls rate by 12% to 4.0/1000 patient Aug 11 4.1 e

a a heightened profile of preventable falls as a corporate 1000 patient days in MSHC, thereby days 4.4 m priority lowering costs, morbidity and mortality 2. Reduce Serious Safety Events (severity level 4 Jan-Dec 10 M Immediate modification of current policy occurred in through the revised corproate policy, e falls) by 25% = 7 m Dec/2010: targeted education and communication 3. Decrease avoid costs from fractured hip related to 5 falls Reduce tbd b

e  increased assessments from once per week to daily regarding falls risk assessment and falls by 5 % (by standarizing care & decreasing resulted in fractures r s prevention :  develop processes; revised policy; created Meditech 6.0 LOS) fractures and due to

N * Average Surgical costs per fractured hip repair: surgical falls by 1- a screens and educated staff on new Post Fall interventions n -decrease morbidity and mortality due to c 2. A complete revision/new policy prepared (Jan- April • Supply cost= $1170.82 per patient repairs 2 y preventable falls during hospital • Staff costs 2 to 3 nurses for 20 minute average= Estimate Cost Potential F 2011) and will be rolled out in May- July 2011). Includes:

l admission e $496.80 per patient x 5 patients= cost

t  iInclude broadened clinical areas; including (Adult inpatient – c

h • Average LOS post hip surgery after fracture 6-9 $4,583.62x5= avoidance

e OBS, PAEDs, ED, Peri-op and out patient areas) - decrease Length of Stay (LOS) of all

r days at approx $486.00/day. Average 6 $22,918.11 savings of ,

 evidenced based; area/unit specific risk assessment and J clinical areas days=$2,916.00 per patient $4,583.62 e

a intervention strategies; including post falls monitoring x 2 = n

- -network with teams in a Community of M  includes detailed communication and documentation tools / $9,167.24

a Practice through SHCN/ RNA O-Falls 4. Estimate cost of legal claims related to falls Current tbd r strategies i e Facilitated Learning Series (FFLS) claims of 3. Goals of the 2011 Falls Prevention Strategy will be to: C

h -standardize assessment and prevention, and intervention and 300k to 1 mil a

n 5.Compliance with fall risk assessment completed Aug 11 – 85% 87% 94% 94% post fall strategies and practice K

i within 24hrs will be 100%. (results obtained by n -increase compliance with fall risks assessments and post falls ,

S monitoring in all clinical areas (measured by audits) audit – all units) h Aug 11 - 87% 87% 96% 93% a 6.Compliance with fall risk assessment daily

r -use multi modal education /Champions for roll out /to o

n increase clinical use thereafter will be 100%.

T Aug 11 - 86% 58% 71% 72% a -examine practice and economic implications of using an 7. Compliance with falls prevention interventions i -

Y evidenced based nursing best practice guideline to improve (visual identifiers) followed is at 100%. o outcomes and avoid extra costs spent due to falls u 8. Decrease by 20% falls causing injury Aug 11- 8.3% 5.0% 13.04% 8.3% n

g -capture data for IHI Cost +Quality initiative project * SHCN/RNAO data on selected units(3C, 3E, ,

R 1C, 1E, UXB) o

g 9. Compliance with at risk patients having a 96.70% 94.87% 95.43% 91.71% xx e

r documented Fall prevention /injury reduction plan

e will be 100% on selected units(3C, 3E, 1C, 1E, r e UXB) z ,

* SHCN/RNAO data S

u 83.65% 83.96% 85.87% 82.98% xx z 10. Compliance with fall risk assessment completed a

n within 24hrs will be 100% on selected units(3C, n

e 3E, 1C, 1E, UXB) * SHCN/RNAO data

Project Charter – v3 –Nov 2010 Page 1 2

Page Recurring Recurring N N N N N Estimate Resource Time Commitment Costs Costs 0 0 0 0 0 5. Project Devel. & Implementation Devel. Project 5. Costs Item Cost 0 0 $5,000 (materials) 0 0 Dept/People Impacted: Time Commit est.) Commit Time 5 days 10 days 5 days year per 2 days per quarter 3 days per quarter 3 days Date Project Approved: Prof Practice, Director,Quality Risk Prof Practice, Director,Quality Risk Prof Practice, Dec. Support, HIM, Finance,Prof ED & Med, Chief of Staff Pharm, Stop/Start Date Dept/People Impacted or Support required Support or Impacted Dept/People Support,Practice, Decision Prof. Management Information Health (HIM), Programs MDs, VP-Clinical Med & front Directors, Managers PPLs, MDs, VP-CP staff, line & front Directors, Managers PPLs, MDs, VP-CP staff, line Finance, Managers,PPLs, MDs, front line staff Practice, Decision Support,Prof ED & Med, Chief of HIM, Finance, Pharm, VP-CP Staff, 2012 Sep 2011 Oct 2011 June 11 /June 12 Start/Stop Date Start/Stop 2011 Feb 28, May 1, 2011 2011 May – June 2011 May – June August 2011 Ongoing thru June develop hrs reduction plan %falls causing injury (i-Report%falls causing injury 3-5) risk assessment completed %pts with at 24 documented% pts with falls prevention/risk Complete PDSA activities related to falls Post Project Charter to SHCN site input 3 measures to SHCN site o o o   8. Evaluate prevention of fall effectiveness program 4b) Activities cycle in first 120 day needed than in 4a) to if more detail indicate impact on other dept/people or support required 7. Participate SHCN/RNAO – FFLS – post data in  uploaded and “Live” June 21/11 5. Develop tool (update audit current); scheduling. and Audit compliance success in meeting performance measures 6. Engage network a Champion to educate and audit preventionfalls and management. 1. Complete Charter Project 2. Complete research / development policy new of 3. Present at committees Policy new Fall Prevention endorsementfor 4. Education/Communication roll out. Policy 4. Project4. Timelines Implementation and Development 6. Risks/Additional Comments: 4a) Project Steps Steps 4a) Project

Vanderlip, Narinder Kainth, Katie Adams, Lindsay Yan, Mary Tang Project

Consultants: Dr. Austin Project v3 –Nov2010 Charter –