viha.ca

Implementing Evidence-Based Care: Falls Prevention

Across Island Health

Excellent health and care for everyone, everywhere, every time.

Catherine HodginsDirector, Clinical Governance, Measurement & Evaluation

Page 2

Disclosure

None

Page 3

Who We Are

• 18,000 Health Care Professionals• 1,900 Physician Partners• 150 + Facilities• 1,565 Acute Care and Rehabilitation Beds• 6,370 Residential Care and Assisted Living

Beds• 1,075 Mental Health & Substance Abuse Beds

Page 4

Legend of the Falls

• We’ve done this before• Multiple Strategies• 2008 – 09 2,353• 2009 – 10 1,968

Page 5

Things Going On2010 - 2013

Page 6

Perspective

2013 -14: 3,274 falls reported

2014-15 YTD: 2819 falls reported 3,331 annualized

$13,300 per fall6.27 additional days

Source: Wong, C. A., and others. The cost of serious fall-related injuries at three Midwestern hospitals. The Joint Commission Journal on Quality and Patient Safety. 37(2):81-87, February 2011.

Page 7

• Falls Prevention Policy• Local Procedures• Falls Learning Hub• Evaluation Framework

Falls Working Group

Page 8

• Falls Prevention Policy• Local Procedures• Falls Learning Hub• Evaluation Framework

Page 9

PSLS implemented for usFalls Prevention PolicyLocal ProceduresFalls Learning HubEvaluation Framework

• Falls Prevention Policy

• Local Procedures• Falls Learning Hub• Evaluation Framework

Page 10

Success

The 2 South team at Royal Jubilee

knows how devastating falls

canbe for patients

and everyone on the team works hard to prevent

them.

Page 11

viha.ca

Surgical Services

Page 13

Page 14

Mental Health & Substance Use Falls Algorithm

Page 15

PSLS implemented for usFalls Prevention PolicyLocal ProceduresFalls Learning HubEvaluation Framework

• Falls Prevention Policy• Local Procedures

• Falls Learning Hub• Evaluation Framework

Page 16

Reality Check

Page 17

How We Are Doing?Completion of Falls Risk Assessment

Page 18

How We Are Doing?Completion of Falls Risk Assessment

74%

26%

YesNo

87%

13%

YesNo

2013-14 2014-15 YTD

Page 19

Jan 2013

Feb 2013

Mar 2013

Apr 2013

May 2013

Jun 2013

Jul 2013

Aug 2013

Sep 2013

Oct 2013

Nov 2013

Dec 2013

Jan 2014

Feb 2014

Mar 2014

Apr 2014

May 2014

Jun 2014

Jul 2014

Aug 2014

Sep 2014

Oct 2014

Nov 2014

Dec 2014

0

50

100

150

200

250

300

350

400

PSLS Falls - South Island - 1JAN2013-31DEC2014All Statuses Except Rejected

DataMean

Page 20

• Falls Prevention Policy• Local Procedures• Falls Learning Hub

• Evaluation Framework

Page 21

Measurement and EvaluationExisting measures• # of Falls per Month• # of Falls per Month with Moderate or Higher Degree of Harm• Of reported Falls,

– % with risk assessment completed– Use of strategies – i.e. hip protectors, nonslip footwear– Time of day; day of week

To be implemented• % of Risk of Falls Screening completed on Admission to service area• % of positively screened patients with a completed falls risk assessment• % of high risk patients with documented interventions noted on the Interdisciplinary Care

Plan

Feedback Loop to service areas for purposes of improvement with specific targets for improvementReport to Program Quality Councils on progress

Page 22

• Implement Strategy• Identify Population at Risk• Address Specific Needs of

Populations at Risk• Establish Measures• Use Evaluation Information for

Improvement

Accreditation

Page 23

Electronic Health Record

Page 24

Expand the Success

Story