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Rapid Fire Team PresentationTeam Call # 3

Name of Presenter: Sheryl L. Courtoreille, RN, BScN, Quality Improvement Coordinator

Name of Organization:Hay River Health & Social Services Authority

Location of Facility: Hay River, NT.

Number of Patients/Residents/Clients:Acute Care – 19Extended Care – 10Woodland Manor Long Term Care - 15

Who We Are

AIM

Team Charter:• Reduce incidence of falls (fall rate) by 40% from baseline by March

2011;• Reduce injury from falls by 40% from baseline by March 2011;• For 100% of inpatients to have a Falls Risk Assessment on

Admission by March 2011;• For 100% of inpatients who have fallen to have a Post Falls

Prevention Injury Reduction Assessment completed by March 2011

Percentage of falls causing injuries – 41%Percentage of patients with completed falls risk

assessment on admission – 30%Percentage of patients with completed falls risk

assessment following a fall – 0%Percentage of “At Risk” patients with a

documented falls prevention/injury reduction plan – 20%

Baseline Data

Team Members

Sue Cullen, CEO – Executive Sponsor

Sheryl L. Courtoreille - Quality Improvement

Coordinator (Lead Contact)

Alex Simms – Occupational Therapist

Jonathan Kennedy – Rehabilitation Aide

Becky Boden, RN – Home Care

Barb Holland, RN – Acute Care

Evelyn Hempal, LPN – Long Term Care

Change Ideas

Falls identifiers for “High Risk” clients to be:

• in the Care Plan;

• outside client room;

• at head of client bed;

• a yellow star label on spine of the client chart at the

nursing station; and

• yellow arm bands (TBA).

MeasuresThere is no direct measurement that is related to our AIM by doing this actionWe are not there yet but we will be there soon!

Comments from clients:• “pretty star”• “how true!”

Comments from Staff:• no resistance to doing this action• staff are recognizing the symbol and implementing identifiers on their own

Measure:• To have 100% of our “high risk” clients identified

Lessons LearnedWhat advice would you give to other teams?

•In order to implement one change, you may need to do a lot of work and implement other changes to get to your original change;

•Ensure any changes/improvements to documentation is realistic;

•Don’t underestimate the education component;

•Start educating and informing staff of what you are trying to accomplish from the start of the project – may help with buy-in.

Key Insights:•Keep your Senior Management Team and Management Team abreast of what you are working on

What were some barriers?• Staffs’ attitude towards changes and/or the idea of change;• Staff lacking education in Falls Prevention Program and its

importance; and • Time needed to dedicate towards this project.

How did you move forward?• Had complete buy in from the Manager of Acute Care & CEO;• Education came in the form of staff meetings with the Manager

and one of our team members;• Both were able to field questions and comments from staff; and• Weekly meetings at a standard time to keep on track.

Challenges

1. Testing a Falls Prevention Injury Reduction Worksheet• Combined the Admission Falls Assessment and Post Falls Assessment onto one

sheet;• Reformatted the Morse Falls Assessment so 5 assessments can be completed

on 1 page;

2. Trialing “Bathroom” signs in the client’s rooms on the bathroom doors;3. Defining a “Toileting Protocol”;4. Transfer card implementation on Acute Care5. Transfer belts in every client room6. Allow time to pass to survey/audit changes and improvements7. Educate, educate, educate!

Next Steps

Name: Sheryl L. Courtoreille, RN, BScN., Quality Improvement Coordinator

Email: sheryl_courtoreille@gov.nt.ca

Phone Number: (867)874-7168

Contact Information