Summary of Action Period 1

TN Patient Safety Collaborative: Reducing Physical Restraints

Learning Session 2

April 7, 8 & 9th, 2009

When We Started

• Learning Session 1, October 2008• Overview of collaborative process• Teams developed goals• Teams learned how to report monthly

progress

• Share common goals• Teach and learn from each other• Provides systematic approach

Why a Collaborative

Sample Aim Statement from a Senior Leader Report

• To reduce restraint use to no more than 2% of our population within 60 days. This will be accomplished by an interdisciplinary team whose focus is to address falls and fall risk and also to develop individual care plans to meet each resident’s personal needs.

Goals/AIM Statements

• To reduce restraints to 10% or less within a six month period

• To reduce and maintain physical restraints to 2% or less in three months by assisting and evaluating the residents currently with restraints and implementing new measures to eliminate these interventions. Will decrease to 1% or less in six months (by April 2009) with the long term goal of being restraint free.

Goals/AIM Statements, cont.

• Collect monthly data from measurement strategy

• Restraint process and outcome measures• Numerators and denominators entered into

data tracking tool

Approach

Data Tracking ToolThis is a Required Outcome Measure  

Data Location: Restraint Log

  Numerator Denominator Measure GOAL

MonitoringMonth

Number of residents physically restrained

on the LAST FRIDAY of the

month

Total number of residents in the census on the

LAST FRIDAY of the month

O3. Percent of residents who were

physically restrained on LAST FRIDAY of the

month# of Missed

Opportunities

INITIAL: 2%LONG TERM: 0%

November-08 9 75 12.00% 9 2%

December-08 8 78 10.26% 8 2%

January-09 9 78 11.54% 9 2%

February-09 5 79 6.33% 5 2%

March-09 6 79 7.59% 6 2%

April-09     #N/A 0 2%

May-09     #N/A 0 2%

June-09     #N/A 0 2%

July-09     #N/A 0 0%

August-09     #N/A 0 0%

September-09     #N/A 0 0%

October-09     #N/A 0 0%

November-09     #N/A 0 0%

December-09     #N/A 0 0%

January-10     #N/A 0 0%

• Data tracking tool shows opportunities for interventions

• Interventions tried/tested through PDSA cycles

• PDSAs are reported on Senior Leader Report

• Senior Leader Report and data tracking tool submitted to QSource monthly

Approach, cont.

• Plan - What is the situation or problem?• Do - What did I do about it?• Study - Did it work?• Act - Based on what I learned, what am I

going to do now?

Plan-Do-Study-Act (PDSA):What it Really Means

Plan-Do-Study-Act (PDSA):The Building Block for Change

“That’s too complicated; I don’t have time for things like that.”

“I’ve got patients to care for and situations to deal with.”

Curing PDSA Phobia

It’s simple as…

P I E

Plan Implement Evaluate

Plan:• Identify the problem.• What steps you will take to try

to fix the problem?• Different actions? • New interventions? • Different equipment?

Implement:• Put your plan into action.• Test your interventions.

Evaluate:• Did your plan work?• Yes? OK, what now?• No? Why not?• What else can we try?

Your answers will leadyou right back to…

Comparing PDSA with PIE

PDSA PIE What it MeansPlan Plan What are we

going to do?Do Impleme

ntPut the plan in motion

Study

Evaluate Did the plan work?

Act Based on what we learned, what will we do next?

Senior Leader ReportIV. Brief Description of Key Changes (PDSA Cycles)

Plan: Who What When Where Why? Do: What actually happened during the test?Study: What did the test data show? What did we learn?Act: Are we ready to implement this change? What will we need to do before the next test cycle? 1. Plan:

Do: Study: Act:

2. Plan: Do: Study: Act:

3. Plan: Do: Study: Act:

4. Plan: Do: Study: Act:

Learning Session 2

Action Period 1: Activities

• Teleconference calls• SLRs and tracking tools• Onsite visit• Weekly team meetings• Distributed SLR newsletters• Completed 2 PDSAs a week• Discussion list serv

Action Period 1: Outcomes

• Teams test on a small scale• Teams establish measurement system

and begin to use data • Teams begin to use other collaborative

participants as resources

Challenges

• Time/staffing issues• Computer skills• Internet access• Complex PDSAs• Completing 2 PDSAs a week• Documentation • Inconsistent data collection

• Measurement strategy • Family and staff reluctance/opposition• Knowledge• Cost• Perception and attitudes

Challenges, cont.

Lessons Learned

• Education is key to change• Creative innovative ideas• Commitment • One person can’t do it all • Don’t assume a restraint is forever;

conditions and situations change • Easier to do things the ‘old way’

• Obtain staff input to increase buy-in when changing the plan of care

• Address individual needs/strengths of the resident and re-evaluate for least restrictive

• It can be done!

Lessons Learned, cont.

• Increased activities, time in group settings,and ambulation are tremendously helpful during restraint reduction

• Involve all disciplines• Diligence and reinforcement• Make it fun

Lessons Learned, cont.

• Look at resident’s behavior to determine personal agenda and respond to residentneeds

• New alternative devices must be tried under close staff supervision during a trial period with careful attention to resident circumstances

Lessons Learned, cont.

• Maintaining a restraint free facility is a daily battle requiring continual assessment and education

Lessons Learned, cont.

Successes

• Increased sharing • Success stories• CNAs take more ownership• Individualized care plans• No restraints upon admission• Using least restrictive device• Reducing restraint usage• Improving quality of life

O1. Proportion of residents physically restrained any time within two calendar days of admission

O2. Percent of residents with falls resulting in serious injury

Group Average: 4.1%

Goal: <10%

O3. Percent of residents who were physically restrained on LAST FRIDAY of the month

Group Average: 7.2%

Goal: 2%

P1. Proportion of residents physically restrained that received a re-evaluation to reduce or eliminate the restraint

Group Average: 68.8%

Goal: 100%

CMS Quality Measure Rate (Nursing Home Compare) Percent of long-stay residents who were physically restrained

QIES Quality Indicator Rate11.1 Residents who were physically restrained

Failure is the opportunity to begin again more intelligently

- Henry Ford

This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services.Contents do not necessarily reflect CMS policy.QSOURCE-TN-PS-2009-05

Summary of Action Period 1 TN Patient Safety Collaborative: Reducing Physical Restraints Learning Session 2

April 2009

Thank You!