www. rapid fire team presentation template name of presenter: sean bisschop
DESCRIPTION
Falls Facilitated Learning Series AIM To engage point-of-care staff and managers in a robust and sustainable fall prevention and harm reduction program.TRANSCRIPT
www.saferhealthcarenow.ca
Rapid Fire Team Presentation TemplateName of Presenter: Sean Bisschop
www.saferhealthcarenow.ca
Falls Facilitated Learning Series
Name of Organization: Orillia Soldier’s Memorial Hospital
Location of Facility: Orillia OntarioNumber of Patients/Residents/Clients: 230 bed community hospital in Ontario’s cottage country; provide regional programs, as well as surgical and medical services to the residents of Simcoe County and Muskoka.
Who We Are
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Falls Facilitated Learning SeriesAIM
To engage point-of-care staff and managers in a robust and sustainable fall prevention and harm reduction program.
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Falls Facilitated Learning SeriesTeam Members
• Ad hoc: point-of-service staff from all participating units • Pauline Stewart, Program Manger – Soldiers’ 2 (Medicine)• Michele Cook, Charge Nurse – Soldiers’ 2 (Medicine)• Lesley Wesley, Program Manager – Harvie 2 (Surgery)• Bonnie Masson & Brenda Prouty – Care Specialists• Sylvia Naughton, Regional Integrated Falls Program• Sean Bisschop, Quality & Patient Safety Coordinator, (Project Lead)• Cheryl Harrison, VP Patient Service/CNE (Project Sponsor)
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Falls Facilitated Learning SeriesReview Falls Change Ideas tested to
date in your organization
Changes Implemented within Organization
Working/Not Working Facilitators/Barriers identified
Feedback and monitoring on compliance with best practices processes
Limited effectiveness B: competing demands and wasteful workflow processes (e.g., unruly paper charting)
F: Data based huddles focus on practice compliance rates; staff problem solve together to reduce waste and increase compliance
Patient mobility needs communication board
Unknown F: Huddles surfaced this idea; undergoing PDSA
Daily unit huddles Working Daily data; shared problem solving; alignment
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Falls Facilitated Learning Series
MeasuresFalls / 1000 pt days % falls with harm
One third of patients who fall at OSMH sustain at least minor/temporary harm
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Falls Facilitated Learning Series
Lessons Learned on Sustaining Falls Improvement Work during Action
Period1. “Falls program” left when previous project lead left OSMH
2. Poor compliance and monitoring of falls standard of care
3. Interventions cannot be reduced to a brief pick list
4. Falls prevention requires all disciplines
5. Assumptions: “people fall – there’s nothing else we can do”
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Falls Facilitated Learning Series
• Wasteful workflows that limits time available for critical thinking
• Little root cause thinking – jumping to address symptoms
• Overly action oriented culture: “Let’s just do something – anything”
• Lack of quality improvement training for point-of-service staff and clinical
leaders
• Changing staff assumptions
Challenges to Sustaining Falls Improvement
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Falls Facilitated Learning Series
6 Month Post FFLS Sustainability Plans for Falls Improvement Work
Goal Description
(What is AIM)
Action
(What STEPS are to be taken to achieve)
Timeframe
(When to be done by)
Person Responsible Metrics: What is to be monitored to identify achievement
Targeted ongoing training and new staff orientation
Provide staff with contributing factors data (e.g., cognitive impairment, use of bed rails, room clutter, benzos)
April 2012 Performance Excellence – Care Specialists
% staff-trained % of falls with harm related to each unit's top two contributing factors
Create quality improvement capacity in local teams to facilitate improve workflow
Train multi-unit staff on Model for Improvement / Rapid cycle Improvement
May 2012 Sean Bisschop, Liz Murray Participation
Improve use of best practice processes through unit-level monitoring of falls prevention & harm reduction best practices
Spread to remaining three inpatient units
June 2012 Inpatient Program Managers % falls risk screening completed% “At Risk” Patients with a documented falls prevention & harm reduction plan
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Falls Facilitated Learning Series
6 Month Post FFLS Sustainability Plan (continued)Goal Description
(What is AIM)
Action
(What STEPS are to be taken to achieve)
Timeframe
(When to be done by)
Person Responsible Metrics: What is to be monitored to identify achievement
Leadership regularly using cascaded Lean Management System to monitor falls improvement work re: Quality Improvement Plan 2012-13
Create Falls focused Leader Standard Work that cascades from Board to bedside
July 2012 Board, CEO, VP Patient Care Services, Directors, Managers
% of leaders completing Falls standard work as per their assigned frequency
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Falls Facilitated Learning Series
Name: Sean Bisschop
Email: [email protected]
Phone Number: 1-705-325-2201 x 3581
Contact Information