We held an improvement collaborative with 19 NHS providers earlier this year to help improve the management of falls in an inpatient setting. This resource shows case studies of the providers involved in the collaborative.

1. NHS Improvement
Falls Collaborative case studies
#improvefalls

2. Background
Falls in hospitals are the most commonly reported safety incident in acute trusts (RPC, 2015). They are particularly
common among older patients (aged 65 and above), with estimates suggesting this group account for approximately 80
per cent of all falls in hospitals. Falls are also the most common source of injury among people aged 65 and above and
are the most common cause of death from injury among the same age group (Kings Fund 2013, Age UK). The National
Reporting and Learning Systems (NRLS) show that there were 246,000 inpatient falls in 2015. Due to underreporting in
some trusts this may be a conservative estimate of incidents and costs
Falls in hospitals can have serious and damaging impacts on health outcomes and patient experience. For older people
in particular, falls can also have detrimental impacts on confidence as well as health and can significantly increase risks
of isolation, reduced independence and the need for residential care (Age UK). Falls also represent significant cost to
acute trusts and the wider healthcare system, with total costs to the NHS from falls among older people alone
estimated at approximately £2bn (Kings Fund, 2013).
There is good evidence (e.g. FallSafe project) that falls could be reduced by up to 25-30% particularly when focused on
wards with older patients. There is a need to move the focus away from looking at what is reported in terms of
incidence, prevalence & rates, to encourage more and better quality reporting. This can be achieved by focusing on
making improvements to interventions for prevention and measuring as a way of capturing real improvement in care for
patients.
One of the clinical safety objectives selected by the Executive Director of Nursing as part of NHSI’s 2020 objective of
implementing patient safety initiatives in priority areas is in regards to falls. To this end a programme of work was
commissioned in August 2016. A review of the number of falls, national and international guidance evidence on falls
prevention was undertaken. The purpose of this review was to establish which providers required help and then to
focus on practice areas that would have the greatest impact using an improvement collaborative approach.
The aims of the collaborative were to:
Improved falls reporting in trusts
Increase Quality Improvement skills in trusts
Reduction in falls on the wards participating in the programme
Encourage falls away from a mainly nursing or patient safety issue towards a multi professional focus
Re-energise the falls prevention improvement movement
Ensure that Trusts have the information & tools to reduce injurious in-patient falls and improve reporting & care
2

3. Introduction
• As part of the collaborative offer at each of the programme days
case studies from exemplar trusts were presented
• This resource has been to support Trusts who did not participate in
the collaborative to have access to the case studies.
3

4. Contents
4
Focus Slide no.
Royal Free NHS Foundation Trust 5 - 34
Rotherham, Doncaster & South Humber Foundation Trust 35 - 66
Huddle up for Safer Healthcare 66 - 99

5. Case Study
Royal Free NHS Foundation Trust
Geetika Singh
Patient Safety Programme Manager
The Royal Free NHS Foundation Trust

6. 24/7 Falls Free Care:
Using IHI breakthrough series
collaborative approach to reduce in-
patient harm from falls
Geetika Singh, Patient Safety Programme Manager
Sarah Rigby, Patient Safety Programme Workstream Lead
Basil Francis, Patient Safety Programme Data Analyst

7. Background
• July 2014, Royal Free London NHS Foundation Trust (RFL) became one
of the largest trusts in the UK by acquiring Barnet and Chase Farm
hospitals (BCF).
• In-patient falls are the second highest reported clinical incident within the
trust.
• All hospital sites implemented a variety of interventions in a variety of
ways to address inpatient falls.
• As RFL, we identified and grouped interventions that led to successful
outcomes.

8. What was needed?
Unique and Innovative
quality improvement
approach in falls
prevention to bring a
large scale change
Collaborative
approach
Building
improvement
capability for
long term
sustainability
Partnership
Model of
improvement
whereby
patient and
staff
engagement
are the
foundations to
our quality
improvement
programme.
Knowledge of
science of
improvement
Subject matter
knowledge

9. Quality Improvement Methodology
The Breakthrough Series - IHI’s Collaborative Model for Achieving Breakthrough Improvement, 2013

10. By 31 March 2018:
• To reduce trust
wide falls rate by
25%.
• To reduce rate of
falls from harm
(moderate,
severe harm or
death) by 20%.
Driver Diagram
Aim Primary Drivers Secondary Drivers Specific ideas to Test
Reliable and
timely
multifactorial
assessment
Reliable and
timely
multifactorial
interventions
Education of
staff, patient
and
family/carers
Understanding
local trends/
themes
Patient specific falls risk
assessment
Staff understand local falls risk to
patients
Falls prevention programme for
staff
Falls care plans developed after
patient risk assessments
Communication of falls risk
status
Falls prevention information for
patient and families
Staff trained and know how to
use assessment tools
Patient specific bedrails risk
assessment
Falls Prevention tool
Staff education on falls tool
Carry out mini RCA for inpatient fall
Create induction leaflet for new staff
and agency staff
Use of visual cues at bedside
Integrate falls risks in ward
handovers and safety briefings
Handover stickers in patients notes
Age UK leaflets
Clear signage
Posters in toilets
Develop training resource
Deliver training programme as per
dosing formula & regular schedule
Develop dosing formula
Monthly analyses of DATIX data

11. By 31 March 2018:
• To reduce trust
wide falls rate by
25%.
• To reduce rate of
falls from harm
(moderate,
severe harm or
death) by 20%.
Driver Diagram
Aim Primary Drivers Secondary Drivers Specific ideas to Test
Understanding
local trends/
themes
Staff understand local falls risk to
patients
Carry out mini RCA for inpatient fall
Monthly analyses of DATIX data

12. Understanding trends and themes
• Organisational Level:
• Pareto charts were used to
identify wards we should be
going to  source was DATIX
• Team’s engagement and
readiness to change
• Participating ward level:
• Pareto charts to identify the
most common risk factors of
falls  Source was DATIX
• Case note review to
understand common themes.

13. Case Note Review
• Derived from:
• FallSafe project
• Transforming Care at
the Bedside:
Reducing Patient
Injuries from Falls,
2012

14. By 31 March 2018:
• To reduce trust
wide falls rate by
25%.
• To reduce rate of
falls from harm
(moderate,
severe harm or
death) by 20%.
Driver Diagram
Aim Primary Drivers Secondary Drivers Specific ideas to Test
Reliable and
timely
multifactorial
assessment
Reliable and
timely
multifactorial
interventions
Understanding
local trends/
themes
Patient specific falls risk
assessment
Staff understand local falls risk to
patients
Falls care plans developed after
patient risk assessments
Communication of falls risk
status
Staff trained and know how to
use assessment tools
Patient specific bedrails risk
assessment
Falls Prevention tool
Staff education on falls tool
Carry out mini RCA for inpatient fall
Monthly analyses of DATIX data

15. Page 1 Page 2

16. Page 3 Page 4

17. Measures
OutcomeMeasures
1. Number of falls
per 1000 occupied
bed days (OBDs)
2. Number of falls
with outcome of
moderate severe,
harm or death per
1000 OBDs
ProcessMeasures
1.No of hours it took to
complete falls assessment
after the patient admission to
the ward.
2. No of hours it took to
review falls assessment from
the previous assessment.
3. No of hours it took to
complete or review falls
prevention plan.
4. No of hours it took to
complete or review bedrail
assessment .
5. % of pts, who fell during
their stay in a ward, received
after falls care as per post
falls protocol within 24hrs
BalancingMeasures
1. % of eligible falls risk pts
receiving specialing services.
2. Patient feedback
3. Staff feedback (patient
safety culture survey).
Quality of care provided:
Post in patient falls case note review and sharing the finding with ward staff.

18. Designing and testing of
measurement tool

19. Designing and testing of
measurement tool
• FallSafe
• National Inpt
falls audit
Falls shared
drive

20. Measurement Tool –version 1

21. Version 14

22. Version 14

23. Version 14

24. Version 14
Leaving
patients alone
in the toilet/on a
commode is
extremely high
risk; balance
the risk of injury
from a fall, with
the patient's
need for dignity’

25. Version 14

26. Version 14

27. Version 14

28. Sharing Data

29. Sharing data
Quality of care provided:
Post in patient falls case note review
and sharing the finding with ward staff.

30. Celebrating Success
Celebrating 730 days without a
fall with harm
10 wards 10 story boards
On-going temperature check of
safety survey
‘All Learn All teach’

31. Patient Safety Culture Survey
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
10. I have made mistake that had the potential to harm patients
7. I always receive a detailed handover of falls r isk for patients in my care
5. The culture in my area makes it easy to learn from the mistakes of others.
16. Disagreements in this clinical area are resolved appropriately (i.e., not…
13. There is a widespread adherence to clinical guidelines and evidence…
3. I am involved in regular safety briefings where falls are discussed
17. There is a comprehensive investigation of influencing/other/ human…
4. As a team, we discuss learning from falls incidents
11. All staff in the organisation take responsibility for patient safety
2. Falls are handled appropriately in my area
6. In my area, it is easy to speak up if I perceive a problem with patient care
12. Patient safety is constantly reinforced as a priority in my area
15. I feel confident in explaining what has happened to a patient or family…
1. I would feel safe being treated here as a patient
9. When I am involved in a patient fall I always complete an incident…
8. I would want a comprehensive checklist completed for my procedure.
14. I report incidents to improve patient safety and practice
Average Score
Average Score for Responses to Patient Safety Culture Survey
Falls Learning Session 1, 2 & 3
Learning Session 1 Learning Session 2 Learning Session 3

32. Lessons learned
• Establishing and supporting champion role is crucial for any
improvement work. One champion is never enough.
• Celebrate success no matter how small.
• Integrating the falls measurement tool into ward routine and
sustaining on-going data collection.
• Timely and regular feedback of ward data. Understanding what
matters to the ward in terms of feeding back data.

33. Journey so far
We are here

34. THANK YOU
FOR FURTHER INFORMATION CONTACT:
GEETIKA.SINGH@NHS.NET

35. RDaSH & FallSafe…
Our story
Sharon Greensill
Trust Physiotherapy Professional Lead
Liz Copley Consultant Occupational Therapist
Older People Mental Health

36. Today’s Presentation
• FallSafe in RDaSH …. where and why did it begin
• How was it rolled out and what we learned –
• How wards organised themselves around picking which
bundle component to focus on
• Implementation and and how progress was
supported/measured
• MDT quality improvement work..
• Dementia friendly environmental adjustments

37. FallSafe: What inspired the RDaSH project?
• In line with the national picture, RDaSH in-patient falls rates varied ward and area to the next
(some of this explainable some not)
• Built naturally on from previous work and RCPhys; NF& BH Audits
• Ongoing checking/updating of work at NPSA, ‘How to prevent..’ guides.
• Wanted to better understand our data and also contribute
• to national benchmarking for mental health
… but mainly….
• In 2014 Commissioners set us a CQUIN for a 25% reduction in
inpatient falls rates!
It tends to focus the mind !!!!!
WHY?

38. RDaSH FallSafe
Launched in 2014

39. STEP 1- The start
• Launch event
• Representatives from each area- key
focus to get people on board
• Selling the concept
• Discussing the anxieties and fears
• Discussing the positives
• Next steps

40. STEP 2- ownership
• Identifying leads and champions – for
each area-
RDaSH ownership –
Brand RDaSH
Designed our own logo
Bags, badges, stickers

41. Internal drivers
• CQUIN payment/ targets set against baseline
• Challenge- not at start of falls prevention work
Previous work had significantly reduced falls
rates
already.
SO WHAT WAS BASELINE
• Spent a lot of time on cleaning up data with data
analyst – this was key
• Data analysis ****

42. STEP 3 – local ownership
• Leads formed ward based teams – skills
mix, ‘who’ was key
• Held their own launch events
• Local ownership
• What worked well … AHP’s , support
workers

43. STEP 4
• Team tasks and approaches
– Planned for each stage – selecting bundles,
looking at how they could be rolled out, identifying
training and other needs related to this
– Feedback/ learning from areas as part of PDSA
approach – monthly audits
– Ward ‘fallsafe’ walk rounds
– mapping patient journeys,
– ‘splat’ diagrams’..
pretty much followed the Fallsafe
book!

44. Implementation: a staged approach
What we learned
• FallSafe Leads in place – their individual level
of engagement and interest was key
• Ward based FallSafe teams, leads had
different ways engaging whole staff group and
building up the approach
• Choosing the components of care bundles –
picked most ‘do-able’ first. Differed by areas

45. • Added care bundles every few weeks/ months
rates led by leads and team
• monthly audits involved audit facilitator
• Sustaining momentum
• Had second event follow up event after 6
months- teams presented their progress and
shared ideas .. Should have done more of
this, but logistics difficult

46. Falls Prevention what else
have we done
FALLSAFE IN PRACTICE

47. Walkabout findings as drivers
• Difficulties with bed sensors – what did we
find
• Handrails on wards- which guide to
destinations
• Chair heights
• Space between tables in dining areas
• Gardens slopes and access
• Environmental layout

48. What did we do
Night time bedroom falls
• Night lights/ bed sensors
• Low Beds / Mats
• Lighting
• Observations
• Sleep hygiene/person centred care
re sleep
• Sleep charts before sedation

49. General falls
• Individual plans re mobility status
• Physio assessment within 48 hours for all
patients admitted OPMHS
• Mobility status logged on ward boards for
whole team awareness
• Falls risk assessment by nursing staff
completed in 12 hours but usually in
admission-simplified assessment

50. Patients
• Footwear
• Walking Aids – roll out of training to issue
walking aids by ward staff. Checking of
walking aids – ferrules, where from,
wheels
• Clothing – belts, braces
• Hydration – ice pops, ice lollies

51. Patients
• History – side of bed, night time toileting, falls
• Toileting plans
• Medication – culprit MDT
• Lying or sitting standing BP for every pt on
admission
• Urinalysis for every pt on admission
• Physio/OT – spatial awareness, strength and
balance exs, engagement , activity
occupation

52. Environment
Principles of Supportive Design
• The environment supports meaningful interaction
between staff
• Supports eating and drinking
• Supports mobility
• Supports continence and independence
• Supports orientation
• Kitwood’s needs- ask are these supported by the
environment?
Comfort , Identity, Occupation, Inclusion, Attachment
Dementia Friendly Environments and principles of
supportive design: King’s Fund EHE

53. Environment
• Colour – use of colour in our environments
• Flooring – to reduce risk of harm from falls
• Lighting – linked to managing BPSD
• Layout – Breaking up spaces
• Signage – pictures and names at correct
height – eye level

54. • Signage – pictures and names at correct
height – eye level
• Interactive artworks and memorabilia –
conversation points. Pictures on corridor
walls
• Places to walk - resting points – chairs on
corridors.

55. • Orientation
Calendars, large face clocks in
every bedroom
Photographs of local scenes
Signs denoting location / ward and
name

56. LEGIBILITY - aided by
• Clear sight lines
• Even lighting, avoid shadows
• Matt, even coloured flooring
• Noise reduction, Uncluttered spaces
• COLOUR CONTRAST very important
WAYFINDING - helped by
• Accent colours
• Identification of spaces using appropriate reference
objects
Dementia Friendly Environments and principles of
supportive design: King’s Fund EHE

57. Pictures on
corridors

58. Pictures of local
interest

61. Up to present day and
onwards…
• Vision
• Postive risk taking ? Reducing 1:1’s
• Falls in dementia patients remain key focus

62. Dementia and Vision/ Perception
Damage to occipital and parietal lobe
• Illusions – distortion of reality
• Misperceptions – ‘best guess’ distorted information
• Misidentifications –problems identifying objects, places
or people
• Problems in processing visual information e.g.
recognising contrast, depth, distance, colour, spatial
awareness difficulties, way-finding problems
exacerbated if lighting is poor or contributing to the
person’s confusion
Context: supportive environments matter

63. Challenges going forward
• Positive risk taking versus managing risks
• Environments themselves
• Maintaining momentum
• Teaching the new…. Almost circle of
starting
again

64. Key Factors
Organisational ownership - bottom to
top
Resources and skill mix
Making it the norm
MDT *******

65. Training
• Every new doctor has training
• 3 year module based training using e
learning RCP
• Learning from Incident
• Learning from Serious Incidents

66. HUSH: a systematic approach to
reducing harm and addressing Safety
Culture at the frontline
Alison Lovatt - Clinical Network Director
April 2017

67. ‘A team of improvement
scientists, patient safety
experts and clinicians who
are committed to working
with frontline services,
patients and the public to
deliver real and lasting
change for the region.’
Yorkshire and Humber AHSN Improvement
Academy
Bring about lasting change
Improvement
Science
Ensure evidence
based solutions
become routine
practice
Co-create
improvement with
frontline clinicians,
patients and public
Address
professional and
geographical
isolation through
network learning
Established May 2013

68. • Increase improvement capability for Y&H
• Complement what organizations already
do
• Exchange ideas in local, national and
international networks
• Clinically led - not telling people what to
do!
• Mobilize our applied research
Why an Improvement Academy?

69. Yorkshire and Humber

70. “In the end, culture will trump
rules, standards and control
strategies every single time, and
achieving a vastly safer NHS will
depend far more on major
cultural change than on a new
regulatory regime”.
Don Berwick 2013

71. A culture of safety
An environment, where everyone regardless of
their title or grade, feels safe to speak up. No
one is hesitant to voice a concern about a
patient or the plan.
When staff do speak up, they are treated with
respect and have confidence that leadership
will act upon their concerns; a cycle of trust.
Psychological Safety

73. Our theory…..
is that if you equip teams with
insight into how they perceive they
work as a team and how safe they
feel their care is then they will take
action to improve things.
By highlighting any dysfunction and
emphasising its link to safety,
teams may “sort themselves out”
Sometimes the results indicate a
team needs “therapy” before they
can improve.

74. In addition……..
• Our observation is that this is an improvement
intervention in itself and helps teams realise
their potential.
• It’s not a tool for Management.
• There is always some cause for celebration and
sometimes the results dispel myths about teams.
• The majority of the elements are within the gift of
the team to address themselves
• The before and after measurement is helpful but
need not be the focus.

75. • Culture should be measured at clinical unit level
“Teams with positive concordant perceptions on their unit provide
safer and better care
Disparate scoring in teams is a strong indicator of dysfunctional
culture”
• An effective team is far more able to recognise when things are
going wrong than any one individual.
• A team that works together well is a safe team
• Clinicians’ perception is often that it’s a great team………..
• How positively nursing input is received particularly by Doctors
correlates with patient outcomes.
And the Evidence………

76. Reducing central line infections in Michigan
Teams with higher culture scores on
teamwork were more likely to reach
goal of no central line infections
44% reached goal in upper third of culture
scores
21% reached goal in lower third of culture
scores

78. Assessment of Safety
Culture
• 28 questions in total
• Background information
• Confidential (includes personal
identifiers) data collection and
anonymised reporting
• Additional Q:
“28. Please give your unit an
overall grade on patient safety”

79. Principles
• Data belongs to teams not management. Free to
use the analysis as they wish.
• Teams must have feedback and a “conversation”
• Point in time. Take at face value don’t need to
over analyse, interpret, justify or defend.
• Team decides what to do. Have further support if
they want and Management listen.

83. Safety Huddles:
bringing fun to the frontline

84. Improvement and continual
learning led by frontline teams
in Yorkshire

85. Patient Safety Huddles
Key Characteristics: marginal gains
• Informed by QI tools and visual feedback
– Review of days since last harm
• Focused meeting about one or more agreed patient harm/s
– Who are the patients most likely at risk of harm?
• Agreed actions
– set of team/individual actions (aimed at reducing risk of patient harm)
• Multidisciplinary frontline team invited to attend
– including non-clinical
• Senior clinical leadership
– Non-judgemental environment and All team staff empowered to speak up
• Daily (Monday - Friday as minimum).
– Predictable time and venue (appropriate to team and context)
– Brief (5-15 minutes)
• Celebration and recognition of milestones

86. Barriers
• “We haven’t got time”
• “We already do this” Board Round/MDT
• “We can’t reduce falls, it’s what are
patients do”
• “All our patients are at risk”
• “We’ll never get the Consultants on board”
• There’s not a time when we can all gather”

87. What's the difference between
a huddle & a handover?
Safety Huddle Handover
Brief 5-10 minutes Can take up to 1 hour
MDT – all included, all levels Often just professionals
Anticipatory Often reactive
Focussed on specific harm/s – safety
focussed
Covers everything!
Patient focused/ Action focused Team management tool
Patients of concern All patients

88. Enablers: what do teams need from
a coach
• A coach
• Encouragement to have a go
• Trust and patience
• Left alone to learn; teams self correct
• Don’t performance manage; it’s not
necessary Not everyone has to be on board
from day one
• Flexibility to adapt the principles to their
environment and patients.

89. The Safety Huddle …
ignites a spirit of learning
Making measurement visible
“We are achieving results now, that none of us thought were possible 12
months ago”
Consultant Medicine for Older People, LTHT

90. The Safety Huddle …
ignites a spirit of learning
Brings the team together to act:
Own the data, own the actions and
anticipate

91. The Safety Huddle …
ignites a spirit of learning
Addressing Teamwork
& Safety Culture

94. Evidence of Impact
Culture
Wards where Teamwork and Safety Climate
surveys have been repeated after reaching
embedded huddles have shown overall
patient safety ratings of ‘good/excellent’
progressed from 77% and 43.5% in the first
survey to 95% and 79% at second survey,
with an overall trend to more positive
answers across the survey.

95. The Safety Huddle …
ignites a spirit of learning
*** Celebrating Success ***

96. Evidence of Impact:
Ward level

97. Moved from LTHT
to Leeds
Community Care

98. Evidence of Impact At Scale:
Leeds Teaching hospitals
Safety Culture
Wards where Teamwork and
Safety Climate surveys have been
repeated after reaching embedded
huddles have shown overall
patient safety ratings of
‘good/excellent’ progressed from
77% and 43.5% in the first survey
to 95% and 79% at second
survey, with an overall trend to
more positive answers across the
survey.
Return on
Investment of 388%

99. Contact Details
www.improvementacademy.org
y@yhahsn.nhs.uk
@Improve_Academy
@HUSH_Safe
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