VISN 8 Patient Safety Center of Inquiry: Journey for Change:

Innovations to Reducing Fall Incidence and Injury

Session 5

Thursday, January 3, 2013

Happy New Year 2013!

Program Goal

To provide VHA healthcare and quality teams with tools and strategies to reduce preventable falls incidence, injury from falls and outline key components of sustaining and spreading successfully.

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Objectives

• Inventory tests of change in fall and injury prevention interventions

• Differentiate types of falls as a basis for analysis of program effectiveness

• Integrate injury prevention into existing fall prevention programs

• Summarize successes ready for adoption and spread

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Looking AheadEight Sessions of Learning and Sharing

• Oct 25th: State of Science of Falls and Injury Prevention• Nov 8th: Integrating Falls and Injury Assessment• Nov 29th: Interventions to Reduce Falls and Harm, Part 1 (Equipment and

Technology)• Dec 20th: Injury Risk Assessment and Communication of Risk• Jan 3rd: Sustain and Spread Improvements in Reducing Falls and Injury from Falls• Jan 17th: Interventions to Reduce Falls and Harm, Part 2 (Intentional Rounding,

Pre-shift Huddle, Post Fall Huddles)• Jan 31st: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation• Feb 7th: Summary of Your Accomplishments

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Session 5: How to Sustain and Spread Improvements

• Apply concepts of Improvement Science (spread and reliability) to Program Improvements in Reducing Falls and Injury from Falls.

• Learn strategies to apply Implementation Science to the Spread of program Successes.

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But first… Let’s hear from you! Report on Session 4 Assignments:

Who would like to share???? What did you learn?• Test integration of injury risk assessment on

admission for 3-5 patients• Test use of the IHI Injury Matrix and ABCS tool on 3-5

patients• Test redesign of visual cues• Trial use of the communication handoff tool during 3-

5 shift / handoff reports• Practice teach back strategies on 2-3 patients

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Julia Neily, RN., M.S., M.P.H.

Julia Neily has worked for the VA in various nursing roles for 27 years. She is currently the Associate Director of the NCPS Field Office. She joined the VHA National Center for Patient Safety in 2002 and has focused on fall and fall related injury prevention and evaluation of patient safety efforts such as cogni tive aids, Ensuring Correct Surgery and Medical Team Training. Julia has a BS in Nursing from the University of New Hampshire, a Master of Science from New Hampshire College and a Masters of Public Health from Dartmouth Medical School.

Improvement

Hold Gains

Spread

Creating a New System

Improvement Hold Gains Spread

BETTER Way!

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

A Model for Improvement

ACT

PLAN

DO

STUDY

Leading Change

• Establish a sense of urgency• Form a powerful guiding coalition• Create a vision• Communicate the vision• Empower others to act• Plan for and create short term wins• Consolidate improvements• Institutionalize new approaches

Kotter, “Leading Change”

Must Be Measurable!

Examples of Aims

Reducing the rate of falls in our

facility by 40% in seven months

Reducing the rate of injuries due to falls in our facility

by 50% in 7 months

Increase the percentage of staff

on our unit who are educated

about our falls prevention

protocol to 100% in 2 months

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

A Model for Improvement

ACT

PLAN

DO

STUDY

Example of a Outcome Run ChartJa

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Feb-

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Apr

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Jun-

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Jul-1

1

Aug

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Sep-

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Oct

-11

Nov

-11

Dec

-11

Jan-

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Feb-

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Mar

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Apr

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May

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Jul-1

2

Aug

-12

Sep-

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0

0.5

1

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3.5

Rate of Falls with Major Injury (#falls with major injury/BDOC*1000)

Falls

with

Maj

or In

jury

Rat

e (fa

lls w

/maj

or

inju

ry/B

DO

C*1

000) Increased rounding intervention

Month

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

A Model for Improvement

ACT

PLAN

DO

STUDY

Strategies to Hold the Gains

• Establish & document standard processes• Make changes to job descriptions• Use measurement and audits• Provide continual feedback• Pay attention to orientation and training• Assign ownership• Remember how you changed - use PDSA

Characteristics of the Innovation:

• Relative Advantage - How much better is the new compared to the old?

• Compatibility - How consistent is this new idea with values, past experience, and needs?

• Complexity - How difficult is this new idea to understand and use?

• Trialability - how easy is it to test the new idea?• Observability - How visible are the results of this new

idea?

What Type of Person Is Adopter?• Innovators - Adventurous, associate with other

innovators, occasionally suspect, intellectual• Early Adopters** - Well respected, opinion-leaders,

role models• Early Majority - Not opinion leaders, think about it

awhile, interact with peers• Late Majority - Require peer pressure• Laggards - Suspicious of new ideas, look to past vs.

the future, sometimes isolated

Tools

• Falls Team Questionnaire (Introduced in Session 1)– Let’s look at this! (handout)

• Worksheet for Testing Change – Let’s look at this too! (handout)

Successful QI Teams• Produce better outcomes clinically and financially• Know one another’s other’s strength and weaknesses, respect

each other, and have often worked together as a team in the past• View their goals to be part of the organization’s key strategic goals• View their team leaders as competent, with the clout to remove

barriers to change• Have more time to complete goals and information systems that

are helpful to them• Have support from front-line staff

– Mills, P. & Weeks, W.B.(2004). Characteristics of successful quality improvement teams: Lessons from five collaborative projects in the VA. Journal on Quality and Safety. 30(3): 152-162

Questions?

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Assignments for Session 6

• Gather data on compliance on one or more key processes (e.g., fall risk assessment, injury risk assessment, communication of risk)

• Identify a champion in an area you want to spread to (another facility, unit).

Next Session

Interventions to Reduce Falls and Harm, Part 2 (Intentional Rounding, Pre-shift Huddle, Post

Fall Huddles) Thursday, Jan 17, 2013

12N-1PM ET

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