Embed Size (px)
Citation preview
Nomination for Excellence in Patient Safety Award
Nominee
Ms. Michelle Samm Director, Quality, Patient Relations & Experience, Patient Safety and IPAC Markham Stouffville Hospital 381 Church Street, Markham 905-472-7373 ext 6916 [email protected]
Nominator
Ms. Barbara Steed EVP, Patient Experience & Chief Practice Officer Markham Stouffville Hospital 381 Church Street, Markham 905-472-7105 [email protected]
Summary
Of common importance to healthcare organizations is an emphasis on reducing falls rates and establishing falls prevention measures through working groups and projects. Yet unique to one acute care organization is a niche Falls Prevention Project (FPP) led by a Falls Prevention Working Group (FPWG) task force to address the rate of harmful falls across all inpatient clinical programs. Harmful falls are identified along a spectrum between mild harm (level 2) and death/permanent disability (level 5). Establishing baseline falls data, the FPWG initially targeted specific inpatient units where harmful falls rates were frequently occurring. Through a multi-factorial falls prevention strategy approach, the FPWG was able to reduce the rate of harmful falls by 30% across various inpatient clinical units. Although the average number of falls per month remained relatively consistent post FPP intervention, the number of harmful falls have steadily decreased monthly from 37.5% in the 2017-2018 fiscal year to 28.4% in the following 2018-2019 fiscal year. Through education to staff internally and community members externally on safe falls prevention practices, this multi-factorial FPP has recently been recognized by Health Quality Ontario as a leading practice to reduce harmful falls and has been added to the Health Standard’s Ontario leading practice library. Use of an information-technology tracking system has ensured that FPP is a sustainable model for clinical leaders and managers to locally monitor rates of harmful falls to ensure falls prevention best practices are put in place for all patients identified at high risk for harmful falls.
3
Excellence in Patient Safety Award – Nomination Template
Nominations must be made by a member of the College. Nominee name: Falls Prevention Working Group at Markham Stouffville Hospital Nominator name: Barb Steed, Executive Vice President Patient Services and Chief Practice
Officer
Report (Limit: 2,000 words. Please respect the word count limit. The College reserves the right to disqualify nominations that exceed the limit.) Please complete the sections below. You are welcome to insert graphs, etc. into the sections.
1. Introduction – Describe the patient safety initiative. Provide context, define the issue(s) at hand, and outline the initiative’s goal, boundaries and scope.
Falls prevention is a topic of great importance to many healthcare organizations. Yet in one acute care facility, this focus took a deeper dive to explore creative ways to prevent patients from experiencing harmful falls that cause personal injury. Through a unique and collaborative Falls Prevention Project (FPP), an interprofessional Falls Prevention Working Group (FPWG) comprising self-enrolled front-line staff, management and Patient Experience Participants (PEP) across three hospital sites within the organization set out to reduce the rate of harmful falls for an inpatient population across clinical programs. FPP evolved out of a need to support select inpatient units experiencing high rates of harmful falls on a spectrum between mild harm (level 2) and death/permanent disability (level 5). In the 2017-2018 fiscal year, 37.5% of all average monthly falls occurring in inpatient units led to harm, and the FPP aimed to significantly reduce this rate the following fiscal year. Launching the FPP involved establishing baseline data through a needs assessment, in which inconsistencies for falls prevention processes, strategies and interventions across inpatient units were detected. Identified variations among falls prevention measures included varied completion rates for falls risk assessments for at-risk patients, and varied completion rates for root cause analyses following falls incidents. Variation was also observed in the implementation of best practice interventions and falls prevention communication gaps with patients, caregivers and families were noted. To address these highlighted inconsistencies, the FPWG met bi-weekly to track harmful falls data and to generate and pilot innovative interventions through PDSA cycles. Key pillars of the FPP include interprofessional teamwork across organizational departments, empowerment of the patient, caregiver, and family voice, senior leadership support, and community outreach and engagement.
4
2. Impact – Has the initiative resulted in improvements and has it achieved the goals outlined above? Please include reporting that demonstrates progress in the following areas:
a. Data that indicates improvement in patient safety outcomes and processes. Success of the FPP resulted in a significant 30% reduction of all monthly harmful falls across inpatient units over 1 fiscal year. Although the average number of falls overall remains relatively consistent across data reports, the number of harmful falls have decreased from 37.5% in the 2017-2018 fiscal year to 28.4% the following 2018-2019 fiscal year. To date, the rate of harmful falls continues to steadily decline as the 2019-2020 period witnessed another drop in harmful falls to 25.9%:
Time Period Falls with Severity
Level 1
(no harm)
Falls with Severity Level 2-5
(mild harm, moderate harm, severe
harm, or permanent disability/death)
Fiscal Year 2017/18 (Q1-Q3) 179 114
Fiscal Year 2018/19 (Q1-Q3) 249 104
Fiscal Year 2019/20 (Q1-Q3) 240 84
Not only has the rate of harmful falls steadily decreased over time, the severity levels of harm has also declined since the implementation of the FPP. Moreover, harmful falls de-escalated from the number one most reported patient safety incident for the hospital to currently the third most reported patient safety incident. The varying levels of success of the FPP is owed to a multi-factorial approach devised by the highly engaged FPWG. The range of innovative falls strategies piloted in the FPP include daily auto-generated reports for clinical managers highlighting at-risk patients for falls to ensure that best practice falls assessments and interventions are provided in a timely manner. Also included are quality-focused huddles in inpatient units to share data on harmful falls incidents with clinical leaders and front-line staff, education for front-line staff on bed-alarm systems provided by a vendor, education by the pharmacy team for flagging at-risk patients based on medication side-effects, job aids with summaries of falls prevention strategies strategically placed in staff work areas such as medication carts to remind staff about the medication impact on falls, falls prevention wrist bands, and high-risk falls signage in patient rooms. Visual environmental aids at bed-side and at workstations on falls prevention practices serves to promote a greater falls consciousness throughout the organization.
b. Relevant accreditation data. As falls prevention related standards were met during the 2018 accreditation review at this acute care facility, the FPP demonstrates a continued organizational commitment to patient safety concerning harmful falls by the senior leadership team. This is evidenced by the inclusion of harmful falls as a priority focus in the Organizational Strategy Map, the Departmental Quality and Safety Plan (QSP) and the current hospital Quality Improvement Plan (QIP). Furthermore,
5
Health Standards Ontario (HSO) has identified the FPP as a leading practice to be included in the leading practices library, which can benefit other organizations striving to meet accreditation standards for falls prevention.
c. Describe how this initiative has impacted patients and providers, has improved the patient experience, has contributed to a safer care environment and has fostered a culture of safety. Please reference the number of patients impacted as a result of the safety initiative.
The impact of the FPP has touched every clinical program within the organization and therefore impacted a diverse patient population. Patients most impacted by the FPP are those at the greatest risk for harmful falls related to factors of age, polypharmacy and complex medical conditions. Visual aid reminders about safe falls practices in strategic areas within patient rooms and on the units has helped to promote a safety culture for ongoing falls awareness. The impact of FPP has also impacted staff, senior leadership and PEP engagement in falls prevention measures through the development of bi-weekly FPWG meetings. The establishment of a weekly senior leadership falls huddle also keeps senior leaders engaged in a commitment to falls prevention programming. Additionally, through external workshops on falls prevention safety practices in eight community sites across York Region, over 200 healthy seniors have received education on staying safe in the community. The following table outlines the community engagement component of FPP where healthy seniors have received falls prevention education to stay safe in the community setting:
Where applicable, include data (graphs, charts, tables, etc.), into the above bullets, that demonstrate the outcomes of the initiative. (25 POINTS)
Falls Prevention Community Engagement Completed FY Quarter Date Location Group Attendance
18/19 Q3 30-Nov-19 Cornell Community Centre (CC) Cornell Older Adults Club 13
18/19 Q4 20-Feb-19 Armadale CC Armadale Older Adults Club 39
19/20 Q1 06-Apr-19 Milliken Church Best Years Fellowship 35
19/20 Q1 07-Jun-19 Cornell CC Cornell Older Adults Club 11
19/20 Q2 03-Sep-19 Uxbridge Seniors Centre Uxbridge Seniors 80
19/20 Q3 08-Oct-19 Angus Glen CC
Carefirst Angus Glen Older Adult Club 12
19/20 Q3 22-Oct-19 Thornhill CC Thornhill Seniors Club 10
19/20 Q3 12-Nov-19 Whitchurch Stouffville CC Carefirst at Stouffville Library 1
6
3. In relation to this initiative, please discuss:
a. Collaboration and teamwork across and at all levels within the organization, including senior management, frontline clinicians and patients and families. (15 POINTS)
Interprofessional collaboration has been a key pillar of the FPP through inclusion of thirty members on the FPWG from a variety of professional backgrounds and patient experiences. FPGW membership includes representation from clinical leadership, allied health, nursing, building services, PEP and a physician. Senior leadership engagement in the FPP furthered falls prevention awareness in the organization by identifying falls safety as a corporate priority and ‘Wildly Important Goal’ (WIG). Moreover, advancing patient safety beyond hospital walls has become a key pillar of the FPP through community outreach on falls prevention. The following images reflect the interprofessional nature of FPWG membership across three hospital sites within the organization, as well as the community out-reach education initiatives for falls prevention:
Images: Members of the Interprofessional FPWG
7
b. System benefits/impact of the program. (10 POINTS)
As the greatest benefit of the FPP to patient safety is a steady decline in harmful falls observed throughout the organization reflected in the control chart below, this successful work has recently been recognized by Health Quality Ontario (HQO) as a leading practice to reduce harmful falls, and included into Health Standard’s Ontario (HSO) leading practice library. The control chart below shows the significant decline in harmful falls as originating at the point of origin of FPWG formation. As the FPP has successfully reduced the rate of harmful falls, this work has also generated a culture-shift on falls safety consciousness across the organization. Antidotal staff feedback has revealed that falls prevention awareness is now more embedded into daily practice and daily conversations.
Image: A community-outreach falls prevention class
Image: Facilitators for the community-out reach education
sessions
8
c. The use of leading practices, implementation of an improvement framework, the introduction of new technologies or innovative approaches that positively impact patient safety. (15 POINTS)
As more healthcare organizations are moving towards opportunities to empower the patient, caregiver, family voice into program design, the FPP has committed to engaging the patient, caregiver, family perspective into falls prevention planning through the participation of PEP members in the FPWG. Utilizing systematic root-cause analyses, the FPWG routinely meets to discuss harmful falls incidents, which leads to collaborative discussions concerning innovative falls strategies to pilot. PDSA cycles are used throughout all pilot stages during falls strategy development. Once piloted, the working group thoughtfully studies the impact of these interventions in comparison to data on harmful falls rates on the units. Based on these data comparisons, the FPWG focuses meetings on brainstorming new innovative practices to continue to facilitate change. Critical to the success of the FPP to track and monitor change in relation to harmful falls data, the development of an information-technology system to produce daily auto-generated reports on patients at high risk of falls ensures that falls risk assessments are completed consistently and timely. The benefit of daily reports also allows for greater engagement of clinical managers to monitor and catch gaps in inconsistent falls assessment practices and to provide real-time intervention for patients most at risk.
d. Integration of the program or initiative in the business plan and/or the patient safety plan. (10 POINTS)
Start of Focus on Falls working group
CL37.2%
25.6%
UCL
67.7%
LCL6.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%2
01
7M
04
20
17
M0
52
01
7M
06
20
17
M0
72
01
7M
08
20
17
M0
92
01
7M
10
20
17
M1
12
01
7M
12
20
18
M0
12
01
8M
02
20
18
M0
32
01
8M
04
20
18
M0
52
01
8M
06
20
18
M0
72
01
8M
08
20
18
M0
92
01
8M
10
20
18
M1
12
01
8M
12
20
19
M0
12
01
9M
02
20
19
M0
32
01
9M
04
20
19
M0
52
01
9M
06
20
19
M0
72
01
9M
08
20
19
M0
92
01
9M
10
20
19
M1
12
01
9M
12
Rat
e o
f Fa
lls w
ith
Har
m
Time Period
u Chart: Rate of Falls with HarmFY 2017/18 to Present
9
The FPP has been embedded into the QIP for the acute care facility and included in the organization’s two-year QSP as a strategic key priority. The FPP has also been included into an organization-wide Corporate Strategy Map. These documents set key quality and safety priorities for the organization and ensuring that FPP was incorporated throughout each level of the hospital’s strategy has added an additional lens of accountability and reporting. This indicates that the falls prevention strategy is fully supported from leadership to front-line. Rate of falls causing harm is included in each clinical program’s monthly program scorecard with an internal report out to senior leaders. Including FPP on the QIP ensures that reports are sent externally to HQO each quarter, as part of the QIP governance.
e. Adoption of a comprehensive approach to program implementation (i.e.: process metrics, performance indicators, educational component, benchmarking, budget, system wide implementation). (10 POINTS)
A baseline assessment on the current state of harmful falls rates in the organization was initially conducted for future program impact analysis. Within the FPP working group, a root cause analysis of select harmful falls incidents was performed to generate change ideas to prioritize. Auto-generated reports for clinical managers to monitor high risk patients on the unit became embedded into routine management practices. Additionally, formation of the FPP working group has enabled a bi-weekly monitoring process to assess the impact of falls prevention strategies for comparisons to baseline data on harmful falls incidents. Visual aids for staff and patients/families on the units have enabled real-time and bed-side educational moments and reminders on falls prevention best practices.
f. The sustainability and replicability of this initiative. (15 POINTS) Collaborations with the information and technology team at the acute care facility allowed for the development of a sustainable auto-generated report system to monitor at-risk patients for falls assessments and interventions. Visual aids on falls prevention practices are now a crucial permanent element of the hospital room environment. Plans to develop a quick reference tool kit to share with staff, patients and families for continued falls prevention education is in progress. Several peer hospitals have reached out to understand the FPP model and to replicate it at their own sites. Moreover, the FPP has been highlighted externally by HQO for a feature on Quorum during Falls Prevention Month to inspire other organizations (https://quorum.hqontario.ca/en/Home/Posts/How-do-you-prevent-falls-in-acute-care-Spotlight-
on-Markham-Stouffville-Hospital)
FPP was also recognized by CPSI, Healthcare Can, HSO and other leading health organizations as a leading practice. This significant external recognition and resource sharing will allow healthcare organizations across Canada to replicate this successful multi-factorial FPP approach.
10
4. Other considerations the nominator feels may be of interest to the committee. As a proactive falls prevention measure, the FPP has placed a high priority on community engagement for disseminating safe aging and falls prevention practices. This important aspect of the FPP demonstrates a pro-active commitment by the acute care organization to promote falls prevention awareness both within and beyond hospital walls. The following images reflect a sample of the multi-factorial strategies piloted and implemented by the FPP:
Image: Job aid summary of falls prevention best
practices as a reminder for staff, patients, caregivers
and families
Image: Safe mobility/transfer poster strategically placed where
patients can see it in the bathroom when sitting on the
toilet
11
Image: High alert falls risk symbol and description of
its use and purpose
Image: Table summary of medications that can increase falls risk. This table is placed on
medication carts in inpatient units
12
5. Conclusion Reducing harmful falls is an important organizational priority that moves beyond addressing the rate of falls to consider ways to reduce harm when falls occur. The FPP is a multi-factorial falls prevention design demonstrating consistent results to impact harm rates for at-risk patients who fall. As the FPP has reduced the rate of harmful falls across clinical programs, a diverse and high-risk inpatient population has benefited from this comprehensive program. This work can therefore inspire other healthcare organizations to address harmful falls by considering a multi-factorial strategy approach, to develop a diverse group of passionate falls prevention advocates, and to consider the creative use of information-technology systems to identify patients at high risk for falls for timely bed-side interventions.
