Collaboration and Proactive Teamwork Used to Reduce (CAPTURE) Falls

International Improvement Science and Research SymposiumApril 21, 2015

Katherine J. Jones, PT, PhDkjonesj@unmc.edu

Conflicts of Interest • Research funded by…

– Nebraska Department of Health and Human Services– Agency for Healthcare Research and Quality

This project is supported by grant number R18HS021429 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

• Travel to attend conferences funded by…– Agency for Healthcare Research and Quality– American College of Medical Quality – American Hospital Association– Nebraska Department of Health and Human Services– University of Nebraska Medical Center– University of Texas Health Science Center at San Antonio

• No other conflicts to disclose

Acknowledgement: Research TeamUniversity of Nebraska Medical Center

– Katherine Jones, PT, PhD– Dawn Venema, PT, PhD– Jane Potter, MD– Linda Sobeski, PharmD– Robin High, MBA, MA– Anne Skinner, RHIA– Fran Higgins, MA, ADWR – Mary  Wood– Kristen Topliff, BA, PT2

University of Nebraska at Omaha Center for Collaboration Science

– Roni Reiter‐Palmon, PhD– Victoria Kennel, MA– Joseph Allen, PhD

Nebraska Medicine– Regina Nailon, RN, PhD

Methodist Hospital– Deborah Conley, MSN, APRN‐CNS, GCNS‐BC, FNGNA

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Objectives

1. Explain the background, rationale, and context of Collaboration and Proactive Teamwork Used to Reduce (CAPTURE) Falls

2. Identify CAPTURE Falls as a complex social intervention (CSI)

3. Evaluate the outcomes of CAPTURE Falls based on extent of implementation and consistency with theory

Falls: Quality and Safety Problem• Prevalence (Oliver et al., 2010)

– 2% - 3% of hospitalized patients fall each year– 30% - 51% of falls result in injury

• Benchmarks from National Database of Nursing Quality Indicators (Staggs et al., 2014)– 3.4 falls/1000 pt. days– 0.8 injurious falls/1000 pt. days

• Outcomes– Cost…$14,000 greater for 2% of fallers with

serious injury (Wong et al., 2011);

– 1/11 Healthcare Acquired Conditions (HACs) PPS hospitals not reimbursed for

– Falls contribute to 40% of nursing home admissions (Tinetti et al., 1988)

– Fear of falling limits mobility (Tinetti et al., 1994) 5

As compared to other HACs, little progress made in decreasing falls since CMS ceased paying hospitals for conditions not present on admission.

Why?

(AHRQ Interim Update)

Evidence indicates that teams decrease fall risk…but how?• Systematic review: Etiology of falls is multifactorial

(Oliver et al., 2004), thus falls require a multifactorial/ interprofessional approach for prevention

• Systematic review: Themes specific to successful implementation of fall risk reduction programs include multidisciplinary implementation and changing attitudes of nihilism (Miake-Lye et al., 2013)

• Cohort pre-post designs: Fall risk has been reduced in studies where interprofessional team members were actively engaged in fall risk reduction efforts (Gowdy et al., 2003; von Renteln-Kruse et al., 2007)

• Theory: Effective teams are the fundamental structure for managing complexity/learning and implementing change in organizations (Edmondson, 2012; Higgins et al., 2012) 7

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Teamwork as a Structure of Care…Donabedian’s Quality Assessment Framework

How care is delivered, organized, financed

People, equipment, policies/procedures

Equivalent to system design, capacity for work

Tasks performed that are intended to produce an outcome

Most closely related to outcomes

Causal relationship between process & outcomes

“Ultimate Validator”

Changes in individuals and populations due to health care

Time to develop, multifactorial, random component

(Donabedian, 2003)

Hypothesis: Rates higher in Critical Access Hospitals (CAHs) (Jones et al., 2014)

1. Care for higher proportion of older adults2. Provide skilled care3. Limited QI resources4. Lack valid fall rate benchmarks5. Continue to receive payment for HACs

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http://www.flexmonitoring.org/wp‐content/uploads/2013/06/CAH_111214.pdf

1. Care for higher proportion of older adults2. Provide skilled rehabilitation 3. Limited QI resources4. Lack valid fall rate benchmarks5. Continue to receive payment for HACs

Fall Risk Reduction Context

• 2011 cross-sectional survey of all 83 community hospitals– No significant differences in prevalence of bedside interventions– CAHs reported performing significantly fewer organizational level

evidence-based processes than non-CAHs– Risk of falls significantly greater in CAHs than non-CAHs– After adjusting for volume, hospitals in which teams integrated

evidence from multiple disciplines and reflected/learned from data had significantly lower fall rates

• Conclusion: shift from nursing-centric to team-centric paradigm to decrease fall risk

• Purpose: decrease risk of falls in nation’s smallest hospitals– Support implementation of customized action plan by

interprofessional coordinating team– Evaluate implementation (structure-process-outcomes)– Develop and disseminate toolkit

http://www.unmc.edu/patient-safety/capturefalls/

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CAPTURE Falls in 17 NE Hospitals

http://teamstepps.ahrq.gov/

MTS Definition and Typology• “Two or more [component] teams that

interface directly and interdependently in response to environmental contingencies toward the accomplishment of collective goals.” – Component teams achieve proximal goals – MTS achieves overarching/organizational goal

• Typology– Composition– Linkages– Development

(Mathieu, Marks, & Zaccaro, 2001, p. 290)

(Zaccaro, Marks, & DeChurch, 2012)

Nursing: Fall Risk Assessment  with High +/‐ Predictive 

Value

PT : Consistent/Safe Transfers & Mobility

QI: Standardize reporting taxonomy 

Pharmacy : Safe Medication Use/ Debridement

Fall Risk

System Information

System Sensemaking

System Action

System Outcome (Fall Rate)

Patient Information

Patient Sensemaking

Patient Action

Patient Outcome (Fall ?)

IP Coordinating 

Team (40% Nursing)

Audit Bedside InterventionsConduct Root Cause Analysis

Benchmark Rates

Conduct Gap Analysis: Integrate Evidence from Mult. DisciplinesConduct Annual /New Emp. Training & Assess Competencies Develop Policies/Procedures (e.g. Communication of Fall Risk) 

Choose Fall Risk Assessment Tool(s)Develop Fall Event Reporting FormsCollect, Analyze Fall Event Data

Provide Feedback about Actions Taken

IP Core Team(84% Nursing)

MTS

Com

pone

nts

and

Link

ages

Data

IP Contingency

Team (56% Nursing)

Event InformationWho, What, When, Where

Event Sensemaking 

How, Why

Complex Social Intervention (Ovretveit,2014)

Characteristics• Multiple components

• Multiple organizational levels

• Requires behavior change

• Multiple outcomes

• Flexible to match gaps and context of each hospital

Evaluation• Context

– Culture assessments, site visits

• Extent of implementation of coordinating team activities– Mean = 43.6/64– Range= 31-57/64

• Outcomes explained by theory

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Extent of implementation of post-fall huddles

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Perceptions of Teamwork and Readiness to Change (TPQ-F)

Change in % Positive Over Time (’13 vs. ‘14) and Huddle Participation (PFH; 0 vs. >0)Admin/Mgt

(n≈ 109)Coord. Team 

(n≈312)Core Team 

(n≈839)Ancillary 

Team (n≈253)Support 

Serv. (n≈149)’13‐’14 PFH ’13‐’14 PFH ’13‐’14 PFH ’13‐’14 PFH ’13‐’14 PFH

Team Structure 58‐64 59‐63 85‐90* 89‐86 87‐87 86‐89* 78‐76 81‐73* 69‐74 67‐77*

Leadership 51‐50 53‐48 77‐88* 85‐82 78‐74* 72‐78* 70‐67 72‐65 63‐60 52‐70*

Sit. Monitoring 64‐58 54‐68* 76‐87* 83‐82 84‐84 84‐84 71‐71 75‐67* 62‐68 59‐70*

Mutual Support 64‐66 62‐68 76‐86* 83‐81 82‐81 81‐83 72‐76 80‐67* 64‐62 57‐69*

Communication 54‐64 59‐59 73‐87* 82‐80 85‐87 87‐85 63‐61 65‐60 55‐55 47‐63*

Management Support

70‐75 69‐76 75‐85* 82‐78 71‐72 69‐74* 62‐62 66‐59* 55‐65* 55‐65*

Hospital Staff Support

79‐81 70‐87* 82‐94* 89‐89 90‐89 90‐89 81‐77 82‐76 70‐74 68‐76

Informal Opinion Leaders’ Support

68‐71 69‐70 82‐88 87‐83 79‐73* 77‐76 66‐60 64‐62 53‐61 56‐58

Hospital Resources 75‐75 68‐81 78‐86* 83‐82 75‐74 74‐75 68‐66 70‐63 56‐52 48‐6016

*p<.05; random effects ANOVA, adj. for nesting by hospital; Time adjusted for participation in PFH 

5.9

4.1

2.11.4

0

1

2

3

4

5

6

7

2010‐2012(Preintervention)

2013‐2014(Intervention)

Event R

ate  / 10

00 Patient Days

Years

Change in Fall Rates Over Time for 17 Small Rural Hospitals in CAPTURE Falls

Total Falls/1000 Pt Days Injurious Falls/1000 Pt Days

Extent of Implementation Associated with Outcome

Extent of Implementation Associated with Outcome

Outcome: Changing AttitudesNurse: “What did we learn about falls? I remember being a student nurse years ago, and one of my patients … had fallen at home. I kind of giggled—so she fell. And the nurse working with me said, ‘Oh, no! In the elderly falls can be lethal, but that’s just part of getting old.’ And we’ve learned that’s not just what happens– we can put things out there to prevent that.”

Physical Therapist: “Teams hold you accountable and build you up.”

Pharmacist: “I might look at something differently than a nurse or QI, so we can kind of talk about it together [in the huddle] and then identify why we think the fall happened and what we can do to improve.”

Summary• CAPTURE Falls is a complex social intervention

developed to decrease fall risk in CAHs

• Evaluation must assess extent of implementation, consistency with theory, and consideration of context…

• Conclusion: Use of MTS increased capacity of small rural hospitals to implement evidence-based fall risk reduction interventions by leveraging complementary skills and diverse thinking of multiple professions and teams

• Next Steps: Online reporting, sustain, spread; opportunity to understand MTS “in the wild”

ReferencesAHRQ. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and

Estimates of Cost Savings and Deaths Averted From 2010 to 2013. Available at http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.html. Accessed March 22, 2015.

Donabedian A. An Introduction to Quality Assurance in Health Care. New York: Oxford University Press; 2003.

Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: John Wiley & Sons; 2012.

Gowdy M, Godfrey S. Using tools to assess and prevent inpatient falls. Jt Comm J Qual Saf. 2003;29(7):363-368.

Higgins MC, Weiner J, Young L. Implementation teams: a new lever for organizational change. J Organiz Behav. 2012;33:366-388.

Jones KJ, Venema D, Nailon R, Skinner A, High R, Kennel V. Shifting the paradigm: An assessment of the quality of fall risk reduction in Nebraska hospitals. J of Rural Health. Published online Sept. 2, 2014; DOI: 10.1111/jrh.12088.

Mathieu JE, Marks MA, Zaccaro SJ. Multi-team systems in N. Anderson, D. Ones, HK Sinangil, & C. Viswesvaran (Eds.), International handbook of work and organizational psychology. London, UK: Sage Publications; 2001: 289-313.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:390-396.

Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age Ageing. 2004;33:122-130

Ovretveit J. Evaluating improvement and implementation for health. Berkshire, England: Open University Press; 2014.

ReferencesStaggs VS, Mion LD, Shorr RI. Assisted and unassisted falls: different events, different

outcomes, different implications for quality of hospital care. Jt Comm Jrnl. 2014;40: 358-364.

Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. The New England Journal of Medicine. 1988;319:1701-1707.

Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994;49:M140-M147.

(TPQ-F) Teamwork Perceptions Questionnaire-Fall Risk Reduction. Available at: http://www.unmc.edu/patient-safety/_documents/cf-teamwork-perceptions-survey-website.pdf . Accessed April 17, 2015.

von Renteln-Kruse W, Krause T. Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention. J Am Geriatr Soc. 2007;55(12):2068-2074.

Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37:81-87.

Zaccaro SJ, Marks MA, & DeChurch LA. Multiteam systems: An introduction. In SJ Zaccaro, MA Marks, & LA DeChurch (Eds.), Multiteam systems: An organization for dynamic and complex environments. New York, NY: Taylor & Francis Group;2012:3-32.