Leadership for falls prevention

Dr Frances Healey, RN, PhDSenior Head of Patient Safety Intelligence, Research & Evaluation

NHS England

FallSafe Regional Quality Improvement project

“Can a ward-based nurse influence all disciplines to embed evidence-based falls prevention care bundles into regular ward practice using a quality improvement approach?”

FALLSAFEEXTENDED EVALUATION

Baseline +12 months +18 months

1 Call Bell in reach 95% 100% 99%

2 Cognitive screen 60% 82% 70%

3 Asked about fear of falling 31% 76% 78%

4 History of falls taken 85% 99% 97%

5 Lying Standing BP 30% 70% 52%

6 Medication review 49% 75% 82%

7 Night sedation not given 66% 87% 90%

8 Safe footwear on feet 93% 98% 99%

9 Urine dip-test 55% 84% 83%

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8

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12

14

16

Reported falls rate per 1000 bed days + rolling 12 month average Reported injurious falls rate per 1000 bed days + rolling 12 month average Falls rate ratio 12 months before full bundle v.12 months after 0.75 (0.68-0.84), p<0.001 Injurious falls rate ratio 12 months before full bundle v.12 months after 0.86 (0.71-1.03), P=0.11

77% certain last fall was

reported

60% certain last fall was

reported

What was different about the FallSafe approach?

• Giving each FallSafe lead enough education and support to make them a confident and knowledgeable specialist within their ward team

• Making sure the basic equipment they would need was available

• Implementing the care bundle in stages rather than all at once, so improvements became manageable rather than overwhelming

• Measuring how well the bundle was being delivered at least every month – but using the results to learn and improve, not to criticise or blame

• Giving the FallSafe leads encouragement to be adaptable and deliver improvements in ways that suited their patients and their teams

• Creating a community where they could exchange ideas with leads who were working in other hospitals and other specialities

What makes a good ward leader?

Ten ward sisters were chosen from different wards, one from each trust whom we agreed were “great”. The consultancy spent a day with each sister, working with them, following them around and asking them lots of questions. Their matron and line manager were also interviewed.They then distilled this information and developed the profile: 13 strengths emerged and every ward sister who participated demonstrated each one.

What makes a good falls prevention leader?

• Use the same technique• Think of someone whose LEADERSHIP in falls

prevention/safety/older people’s care you really admire

• Discuss and compare with the experience of your neighbours in the room

• What shared qualities/strengths do all the leaders you admire have in common?

• Write those qualities/strengths one per sticky note

If you were curious…

“Caring” did not emerge in the profile…..but instead an absolute need to do the right thing. These people are not rule breakers by nature, nor are they naturally assertive; they are modest and self-effacing. But because doing the right thing for their patients is so important, they will break the rules if they feel they have to (always ensuring patient safety is not compromised) − they just don’t enjoy doing it.

“Is providing excellent nursing care and getting the basics right one of your deepest beliefs? Do you love developing others to become excellent at what they do? Is making a difference and doing the right thing fundamental to you? If your answer to these questions is yes, the ward sister/charge nurse role may be right for you.”

Fair and just culture of incident investigation

Falls aftercare‘Have they hurt themselves falling, or fallen because of new illness?’

Post-fall review and care planning ‘How do I stop THIS patient falling again?’

All are important ……

Root Cause Analysis (RCA)‘How do I learn from this fall to help stop OTHER patients falling in the future?’

How we act in respect to individual staff members after investigation

“The single greatest impediment to error prevention is that we punish people

for making mistakes”

Dr Lucian Leape, Harvard School of Public Health

Regulatory and legal frameworks differ, principles of meaningful and fair investigation do not

The Incident Decision Tree

Structured questions move through 4 ‘tests’• The Deliberate Harm Test• The Physical and Mental Health Test• The Foresight Test• The Substitution Test

Developed by the UK National Patient Safety Agency based on the work of Professor James Reason

Were the adverse

consequences intended?

Guidance on appropriate

management action, centred on support to become fit to work safely

again

Guidance on appropriate

management action, centred

on criminal sanctions

Guidance on appropriate

management action, may be training/insight/

supervision needs

No management action to be

directed at staff involved -

systems failure

Guidance on appropriate

management action, centred on disciplinary

sanctions

The Incident Decision Tree

YES

Is there evidence of physical or mental ill-health?

Were the adverse

consequences intended?

Guidance on appropriate

management action, centred on support to become fit to work safely

again

Guidance on appropriate

management action, centred

on criminal sanctions

Guidance on appropriate

management action, may be training/insight/

supervision needs

No management action to be

directed at staff involved -

systems failure

Guidance on appropriate

management action, centred on disciplinary

sanctions

GROUP WORK: Incident Decision Tree Try the Incident Decision Tree for one of the staff in the case studyDoes the action it leads you to feel fair and just?

YES

Is there evidence of physical or mental ill-health?