Road map to reducing patient falls using an integrative approach toronto grace health centre


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Road map to reducing patient falls using an integrative approach toronto grace health centre

  1. 1. Road Map to Reducing Patient Falls using an Integrative Approach Date: October 18th, 2013 Submission: Virtual Poster Presentation at the Canadian Patient Safety Institute (CPSI)’s Virtual Forum, Canadian Patient Safety Week 2013 Lead Author: Ivan Ip, Director, Quality, Risk & Safety/Chief Privacy Officer Contributors: Leo Chow, Patient Care Coordinator Josh Moralejo, Nursing Practice Leader Barbara McKenzie, Staff Physiotherapist Emily Ho, Staff Occupational Therapist
  2. 2. Issue, Intervention and Measurement What is the Issue? • Between 42 and 48% of reported incidents are related to patient falls. How did we identify it? • Reviewing Quality/Risk Indicators from RAI Assessment, Patient Bedside Mobility Assessment, and Incidents Analysis What is our Goal? • To reduce patient falls by integrating evidence-based falls guidelines into our interprofessional practice. What are the Interventions? • • • • Patient Falls Prevention Policy and education Modified bedside patient mobility tool for identifying level of falls risk Patient/family information pamphlet to raise falls awareness Least Physical Restraint Policy and education Measurement: • Monthly reported number of patient falls incidents, number of patient days, moving range, ratios of number of falls and number of patient days; and the number and frequency of patients with 2 or more falls were measured and analyzed using (a) u Control Charts for screening and (b) Individual and Moving Range (mR = 2) Control Charts at two and three standard deviations to examine variation, pattern and extreme points. Baseline Data: • • Facility-wide and Unit-based data between Jan 2011 – Sep 2013 (variable data: Month, Number of patient days and number of reported patient falls). Number and Frequency of patients with 2 or more falls by Unit between Jan 2011 – Sep 2013
  3. 3. Contribution of the Initiative and Lessons Learned Contribution to Patient Safety and Quality Improvement—A Roadmap—2012 – 2014: • • • • • • Increase staff competency in identifying patient at risk of falls Identify opportunities of mitigating these risks by linking related initiatives and relevant information using an integrative thinking and evidence-informed team-based approach. RAI Assessment training provides an underpinning of the knowledge and skills. Goldcare system offers an e-documentation platform timely interprofessional communication Quarterly measurements against the baseline and realistic targets and institute appropriate course correction for sustainable quality improvement effective Q3 of F2013/14. Expected progressive change/improvement in 2014: – – Reduced patient falls and both the number and frequency of falls amongst patients with 2 or more falls Improved compliance rate in the appropriate use of physical restraints; and enhanced quality and utilization of Falls Avoidance care plan for patients identified as at higher risk of falls. Lessons Learned: • • Team goal development was transitioned to reflect unique population-based quality improvement targets and a realistic time line which shows important milestones on when targets will be met Visual process mapping provide the power of integration; and serves as an effective tool for capturing business process, integrating knowledge and people into effective teams through sound communication; and managing complexity of the processes.
  4. 4. Road Map to Reducing Patient Falls using an Integrative Approach Collaboration Debate Communication, Team and Capacity Building Visual Process mapping facilitates the collaborated team to: • Review the Data and Analyze Strategize tRAIn Evaluate Decide Measurements • Learn and understand the meaning of the data and measured results • Know what to do about it • Know how to change it • Believe it and own it • Enable coordinated and coherent Action to drive sustainable change and the integration of best practice Process Mapping Best Practice Integration RAI training for all clinical staff to promote sustainable change and quality improvement Predict Patient Falls Issue Filtering Patient Falls Issue to develop a strategy for an integrated and coordinated approach Measure Mapping Strategy for Prevention and Falls Reduction Model Developed a Falls Prevention Policy and Online Education Program Implemented a bedside mobility tool for risk identification Developed a least physical restraint education program to reflect new guidelines from the Least Restraint Policy Achieve progressive reduction in patient falls and falls related injury in 2014