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ight

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ldquoPreventing Falls Utilizing the Targeted Solutions Toolregrdquo

wwwcenterfortransforminghealthcareorg

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ight

The

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on

Objective To help attendees gain a deeper understanding of the work of the Joint Commission Center for Transforming Healthcare high reliability in health care and robust process improvement

To present the Preventing Falls Targeted Solutions Toolreg (TSTreg) methodology and analytical capabilities

To present how one organization implemented a successful falls prevention project using the Preventing Falls Targeted Solutions Toolreg(TSTreg) and achieved significant improvement in all falls and falls with injuries

Click on the hyperlinks to access additional information

Ask questions through the chat box during our QampA session

Interactive Innovative

THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS

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ight

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issi

on

This webinar is approved for 10 Continuing Education Credit from

Accreditation Council for Continuing Medical Education (ACCME)

Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and

Training (IACET)

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

CECMECEU are available for the live audio only Credits will not be available for webinar replays

In order to claim credits you must have

Individually registered for the webinar through The Joint Commission website

Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only

Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate

Continuing Education Credit

copy C

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ight

The

Joi

nt C

omm

issi

on

The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity

Dawn Glossa MPA Director Corporate Communications The Joint Commission

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare

Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare

Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital

Disclosure Statement

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

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ight

The

Joi

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omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

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opyr

ight

The

Joi

nt C

omm

issi

on

Objective To help attendees gain a deeper understanding of the work of the Joint Commission Center for Transforming Healthcare high reliability in health care and robust process improvement

To present the Preventing Falls Targeted Solutions Toolreg (TSTreg) methodology and analytical capabilities

To present how one organization implemented a successful falls prevention project using the Preventing Falls Targeted Solutions Toolreg(TSTreg) and achieved significant improvement in all falls and falls with injuries

Click on the hyperlinks to access additional information

Ask questions through the chat box during our QampA session

Interactive Innovative

THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

This webinar is approved for 10 Continuing Education Credit from

Accreditation Council for Continuing Medical Education (ACCME)

Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and

Training (IACET)

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

CECMECEU are available for the live audio only Credits will not be available for webinar replays

In order to claim credits you must have

Individually registered for the webinar through The Joint Commission website

Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only

Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate

Continuing Education Credit

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity

Dawn Glossa MPA Director Corporate Communications The Joint Commission

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare

Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare

Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital

Disclosure Statement

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Objective To help attendees gain a deeper understanding of the work of the Joint Commission Center for Transforming Healthcare high reliability in health care and robust process improvement

To present the Preventing Falls Targeted Solutions Toolreg (TSTreg) methodology and analytical capabilities

To present how one organization implemented a successful falls prevention project using the Preventing Falls Targeted Solutions Toolreg(TSTreg) and achieved significant improvement in all falls and falls with injuries

Click on the hyperlinks to access additional information

Ask questions through the chat box during our QampA session

Interactive Innovative

THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

This webinar is approved for 10 Continuing Education Credit from

Accreditation Council for Continuing Medical Education (ACCME)

Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and

Training (IACET)

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

CECMECEU are available for the live audio only Credits will not be available for webinar replays

In order to claim credits you must have

Individually registered for the webinar through The Joint Commission website

Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only

Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate

Continuing Education Credit

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity

Dawn Glossa MPA Director Corporate Communications The Joint Commission

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare

Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare

Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital

Disclosure Statement

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

Click on the hyperlinks to access additional information

Ask questions through the chat box during our QampA session

Interactive Innovative

THE WEBINAR REPLAY AND SLIDE PRESENTATION WILL BE AVALIABLE ON THE JOINT COMMISSION WEBSITE IN 5-7 BUSINESS DAYS THE REPLAY WILL ALSO BE SENT TO ALL REGISTERED EMAILS

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

This webinar is approved for 10 Continuing Education Credit from

Accreditation Council for Continuing Medical Education (ACCME)

Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and

Training (IACET)

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

CECMECEU are available for the live audio only Credits will not be available for webinar replays

In order to claim credits you must have

Individually registered for the webinar through The Joint Commission website

Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only

Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate

Continuing Education Credit

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity

Dawn Glossa MPA Director Corporate Communications The Joint Commission

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare

Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare

Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital

Disclosure Statement

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

This webinar is approved for 10 Continuing Education Credit from

Accreditation Council for Continuing Medical Education (ACCME)

Accreditation Council for Pharmacy Education (ACPE) American Nurses Credentialing Center (ANCC) American College of Healthcare Executives (ACHE) California Board of Registered Nursing Certified Joint Commission Professionals (CJCP) International Association for Continuing Education and

Training (IACET)

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

CECMECEU are available for the live audio only Credits will not be available for webinar replays

In order to claim credits you must have

Individually registered for the webinar through The Joint Commission website

Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only

Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate

Continuing Education Credit

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity

Dawn Glossa MPA Director Corporate Communications The Joint Commission

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare

Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare

Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital

Disclosure Statement

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

CECMECEU are available for the live audio only Credits will not be available for webinar replays

In order to claim credits you must have

Individually registered for the webinar through The Joint Commission website

Listened to the webinar in its entirety Only those listening live on the day of the call will be eligible to receive credit This is an educational program being offered to our accredited organizations only

Completed a post program evaluationattestation A link to the post program evaluationattestation will be sent to your registered email 24-48 hours after the webinar After completion of the survey you will receive a certificate available to download You are responsible for printing and filling out your own CE certificate

Continuing Education Credit

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity

Dawn Glossa MPA Director Corporate Communications The Joint Commission

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare

Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare

Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital

Disclosure Statement

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

The following staff and speakers have disclosed that neither they nor their spousespartners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity

Dawn Glossa MPA Director Corporate Communications The Joint Commission

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for Transforming Healthcare

Anne Kilpatrick RN BSN CSSBB Black Belt Falls Project Lead Joint Commission Center for Transforming Healthcare

Beth Neidlinger RN CENP Coordinator Workforce Development and Professional Outcomes Trinity Mother Francis Hospital

Disclosure Statement

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Erin S DuPree MD FACOG Chief Medical Officer and Vice President The Joint Commission Center for

Transforming Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Utilizing the Targeted Solutions Toolreg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls Background

Hundreds of thousands of patients fall in hospitals each year

Between 30 to 35 percent of patients who fall sustain an injury

Each of these injuries on average add 63 days to the hospital stay

Cost for a fall with injury is about $14056

10

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

All people always

experience the

safest highest

quality best-value

health care across

all settings

One Vision

11

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The

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Leadership

12

MISSIONTo transform health care into a high-reliability industry by developing highly effective durable solutions to health carersquos most critical safety and quality problems in collaboration with health care organizations by disseminating the solutions widely and by facilitating their adoption

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Performance Improvement

We have learned fromMajor corporations (for example GE Lilly

BD Cardinal)Extensive experience with 27 hospitals

and systems that use RPI (Joint Commission Center for Transforming Healthcare)

Joint Commission internal experience

13

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LeadershipSafety Culture

Robust Process

Improvementreg

FROM LOW TO HIGH RELIABILITY

14

Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90

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The

Joi

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15

Excellence in patient care for every patient every time

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The

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on

ZERO

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The

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on

17

Facilitating Change

Six SigmaLean

ROBUST PROCESS IMPROVEMENTreg

FOCUS IS ON THE PATIENT

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Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks

ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51

Colorectal SSIs 32Falls with injury rate 62Falls rate 35

Milbank Q 201391459-90J Nurs Care Qual 20142999-102

ROBUST PROCESS IMPROVEMENTreg

18

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A Systematic Approach for Complex Problem Solving

Define amp measure the impact of the

problem

Discover specific causes

Solutions are targeted to

each specific cause

DEFINE amp MEASURE ANALYZE IMPROVE amp

CONTROL19

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The

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Top Contributing Factors

12

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Targeted Solutions

13

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ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

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TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

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Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

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Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

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Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

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TST Navigation

27

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Training Data Collectors

28

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The

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Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

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Identifying Top Contributing Factors

30

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Measuring Outcomes

31

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Solutions

32

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The

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Solution Guide

33

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Action Plan

34

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Control Plan

35

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27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

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Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

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LeadershipSafety Culture

Robust Process

Improvementreg

FROM LOW TO HIGH RELIABILITY

14

Chassin MR Loeb JM High-Reliability Health Care Getting There from Here Milb Q 201391(3)459-90

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

15

Excellence in patient care for every patient every time

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ZERO

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

17

Facilitating Change

Six SigmaLean

ROBUST PROCESS IMPROVEMENTreg

FOCUS IS ON THE PATIENT

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks

ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51

Colorectal SSIs 32Falls with injury rate 62Falls rate 35

Milbank Q 201391459-90J Nurs Care Qual 20142999-102

ROBUST PROCESS IMPROVEMENTreg

18

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

A Systematic Approach for Complex Problem Solving

Define amp measure the impact of the

problem

Discover specific causes

Solutions are targeted to

each specific cause

DEFINE amp MEASURE ANALYZE IMPROVE amp

CONTROL19

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Top Contributing Factors

12

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

15

Excellence in patient care for every patient every time

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ZERO

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

17

Facilitating Change

Six SigmaLean

ROBUST PROCESS IMPROVEMENTreg

FOCUS IS ON THE PATIENT

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks

ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51

Colorectal SSIs 32Falls with injury rate 62Falls rate 35

Milbank Q 201391459-90J Nurs Care Qual 20142999-102

ROBUST PROCESS IMPROVEMENTreg

18

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

A Systematic Approach for Complex Problem Solving

Define amp measure the impact of the

problem

Discover specific causes

Solutions are targeted to

each specific cause

DEFINE amp MEASURE ANALYZE IMPROVE amp

CONTROL19

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Top Contributing Factors

12

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ZERO

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

17

Facilitating Change

Six SigmaLean

ROBUST PROCESS IMPROVEMENTreg

FOCUS IS ON THE PATIENT

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks

ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51

Colorectal SSIs 32Falls with injury rate 62Falls rate 35

Milbank Q 201391459-90J Nurs Care Qual 20142999-102

ROBUST PROCESS IMPROVEMENTreg

18

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

A Systematic Approach for Complex Problem Solving

Define amp measure the impact of the

problem

Discover specific causes

Solutions are targeted to

each specific cause

DEFINE amp MEASURE ANALYZE IMPROVE amp

CONTROL19

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Top Contributing Factors

12

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

17

Facilitating Change

Six SigmaLean

ROBUST PROCESS IMPROVEMENTreg

FOCUS IS ON THE PATIENT

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks

ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51

Colorectal SSIs 32Falls with injury rate 62Falls rate 35

Milbank Q 201391459-90J Nurs Care Qual 20142999-102

ROBUST PROCESS IMPROVEMENTreg

18

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

A Systematic Approach for Complex Problem Solving

Define amp measure the impact of the

problem

Discover specific causes

Solutions are targeted to

each specific cause

DEFINE amp MEASURE ANALYZE IMPROVE amp

CONTROL19

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Top Contributing Factors

12

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Center Projects Results()Hand hygiene 71Hand-off communication failures 56Wrong site surgery risks

ndash Scheduling 46ndash Pre-op 63ndash Operating Room 51

Colorectal SSIs 32Falls with injury rate 62Falls rate 35

Milbank Q 201391459-90J Nurs Care Qual 20142999-102

ROBUST PROCESS IMPROVEMENTreg

18

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

A Systematic Approach for Complex Problem Solving

Define amp measure the impact of the

problem

Discover specific causes

Solutions are targeted to

each specific cause

DEFINE amp MEASURE ANALYZE IMPROVE amp

CONTROL19

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Top Contributing Factors

12

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

A Systematic Approach for Complex Problem Solving

Define amp measure the impact of the

problem

Discover specific causes

Solutions are targeted to

each specific cause

DEFINE amp MEASURE ANALYZE IMPROVE amp

CONTROL19

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Top Contributing Factors

12

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Top Contributing Factors

12

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Targeted Solutions

13

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

ConfidentialSeparate from AccreditationComplimentary

Guided Robust Process Improvement Measure current state Analyze causes Select targeted solutions Sustain and spread

improvements

14

Preventing Falls

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TSTreg Development Using RPI

Initial 5 Center hospitalsndash 30 different causes varied by hospitalndash Reduced falls with injury rate by 62ndash Reduced falls rate by 35

Pilot 7 hospitalsndash Tested and validated methodology

Preventing Falls

15

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Preventing Falls with InjuryImplications of a Robust Approach

200 Bed Hospital

Expect 358 fallsyrndash 117 injuriesndash $17M in costs

Annual impactndash 72 fewer injuriesndash $1M in costs

avoided

16

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Anne Kilpatrick RN BSN CSSBB Black Belt Falls

Project Lead Joint Commission Center for Transforming

Healthcare

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Request Access

If you already have a user name and password click

here

If you do not have a user name and password click

here

26

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

TST Navigation

27

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Training Data Collectors

28

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Data Collection Form

Both Electronic and Paper Form Include ldquoSkip Logicrdquo

20

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Identifying Top Contributing Factors

30

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Measuring Outcomes

31

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solutions

32

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Solution Guide

33

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Action Plan

34

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Control Plan

35

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

27

TSTreg Feedback

Focused Systematic ApproachData Collection Form Asks ldquoRightrdquo QuestionsHelps Us Understand Our Root CausesDrills Down to Detail We Need to Implement

Efficient SolutionsEmphasis is on Process Not Blaming PeopleThe Training is ExcellentTSTreg and the Paper Form Are Easy to Use

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

copy C

opyr

ight

The

Joi

nt C

omm

issi

on

Take a Stand Against Patient Falls

37

wwwcenterfortransforminghealthcareorg

or e-mail tst_supporttstorg

Beth Neidlinger MSN RN CENP

TST Fall Prevention Project Update

Beth Neidlinger MSN RN CENP

March 18 2016

About Trinity Mother Frances Hospitals amp Clinics

bull Located in Tyler TX

bull Smith Countyrsquos largest employer

bull One of the highest rated integrated health systems in the United States

bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region

Project Background

bull Unit Selection

bull Preparation

bull Task Force Role amp Responsibilities

bull Goals

ndash Falls with injury (FWI)

ndash Total Falls

bull Methodology

bull Project status

Organization Falls Structure

bull Oversight Committee

bull TST Falls Task Force

bull Falls Committee

ndash Quality amp Safety Committee

bull Unit Based Councils

Organizational Data

Source Center for Transforming Healthcare 332016

Trinity Mother Frances Preventing Falls

4 Dawson

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0939 0000 100000 3443 1241 63956

4 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

2283 0000 100000 7626 3965 48007

5 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0744 0263 64651 2975 2630 11597

Contributing Factors All Falls 4Orn

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

TST Fall Prevention Project Update

Beth Neidlinger MSN RN CENP

March 18 2016

About Trinity Mother Frances Hospitals amp Clinics

bull Located in Tyler TX

bull Smith Countyrsquos largest employer

bull One of the highest rated integrated health systems in the United States

bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region

Project Background

bull Unit Selection

bull Preparation

bull Task Force Role amp Responsibilities

bull Goals

ndash Falls with injury (FWI)

ndash Total Falls

bull Methodology

bull Project status

Organization Falls Structure

bull Oversight Committee

bull TST Falls Task Force

bull Falls Committee

ndash Quality amp Safety Committee

bull Unit Based Councils

Organizational Data

Source Center for Transforming Healthcare 332016

Trinity Mother Frances Preventing Falls

4 Dawson

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0939 0000 100000 3443 1241 63956

4 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

2283 0000 100000 7626 3965 48007

5 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0744 0263 64651 2975 2630 11597

Contributing Factors All Falls 4Orn

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

About Trinity Mother Frances Hospitals amp Clinics

bull Located in Tyler TX

bull Smith Countyrsquos largest employer

bull One of the highest rated integrated health systems in the United States

bull Employs over 4000 and includes six hospitals and 36 clinics with over 350 physicians and mid-level providers located throughout the region

Project Background

bull Unit Selection

bull Preparation

bull Task Force Role amp Responsibilities

bull Goals

ndash Falls with injury (FWI)

ndash Total Falls

bull Methodology

bull Project status

Organization Falls Structure

bull Oversight Committee

bull TST Falls Task Force

bull Falls Committee

ndash Quality amp Safety Committee

bull Unit Based Councils

Organizational Data

Source Center for Transforming Healthcare 332016

Trinity Mother Frances Preventing Falls

4 Dawson

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0939 0000 100000 3443 1241 63956

4 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

2283 0000 100000 7626 3965 48007

5 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0744 0263 64651 2975 2630 11597

Contributing Factors All Falls 4Orn

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Project Background

bull Unit Selection

bull Preparation

bull Task Force Role amp Responsibilities

bull Goals

ndash Falls with injury (FWI)

ndash Total Falls

bull Methodology

bull Project status

Organization Falls Structure

bull Oversight Committee

bull TST Falls Task Force

bull Falls Committee

ndash Quality amp Safety Committee

bull Unit Based Councils

Organizational Data

Source Center for Transforming Healthcare 332016

Trinity Mother Frances Preventing Falls

4 Dawson

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0939 0000 100000 3443 1241 63956

4 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

2283 0000 100000 7626 3965 48007

5 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0744 0263 64651 2975 2630 11597

Contributing Factors All Falls 4Orn

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Organization Falls Structure

bull Oversight Committee

bull TST Falls Task Force

bull Falls Committee

ndash Quality amp Safety Committee

bull Unit Based Councils

Organizational Data

Source Center for Transforming Healthcare 332016

Trinity Mother Frances Preventing Falls

4 Dawson

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0939 0000 100000 3443 1241 63956

4 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

2283 0000 100000 7626 3965 48007

5 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0744 0263 64651 2975 2630 11597

Contributing Factors All Falls 4Orn

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Organizational Data

Source Center for Transforming Healthcare 332016

Trinity Mother Frances Preventing Falls

4 Dawson

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0939 0000 100000 3443 1241 63956

4 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

2283 0000 100000 7626 3965 48007

5 Ornelas

Baseline Falls wInjury

Improve Falls wInjury

Relative Change Baseline Falls Improve Falls Relative

Change

0744 0263 64651 2975 2630 11597

Contributing Factors All Falls 4Orn

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Contributing Factors All Falls 4Orn

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Contributing Factors Falls wInjury 4 Orn

bull NO FALLS WITH INJURY SINCE IMPROVE PHASE

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Location All Falls 4Orn

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Injury Level All Falls 4Orn

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Improvement Plan

bull Robust Process Improvement approach

ndash Use of TST Toolkit- linked contributing factors to improvement activities

ndash Enhanced by EBP

ndash Data supported

bull Rapid Cycle Change

ndash UBC driven

bull Pilot persuade promote

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Improvement Activities

bull Assistancecall bell action steps

ndash Purposeful rounding

ndash 5 Prsquos

ndash Hardwiring evidence

bull Rounding audits

bull Staff accountability

ndash Staff contractagreement

ndash Patient contract

bull Toileting

ndash Design program

ndash Scripting

ndash Bedside commodes

ndash ldquoKeep foot in the door to keep your patient off the floorrdquo

ndash Armrsquos reach

ndash White board use

ndash Documentation amp tracking

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Improvement Activities

bull Communication

ndash Data

ndash Staff meetings

ndash Huddles

ndash Falls Hall of FameShame- Bright Ideas Program

ndash Employee recognition-Bright Ideas Program

ndash TMF ldquoMotherboardrdquo with action plans

bull Educationawareness

bull Signage-

ndash RYG (Education UBC project 216)

ndash Cautionceiling ldquoCall Donrsquot Fallrdquo- launched 1115

bull Hourly rounding focus amp audits- launched 1115

bull Foot in the Door- launched 23 (4 Orn UBC)

bull Toileting protocol- launch 218 (4 D UBC)

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Improvement Activity

A FOOT IN THE DOOR

KEEPS PATIENTS OFF

OF THE FLOOR Preventing falls one patient experience at a time

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Foot in Doorbull Signage

ndash Promotes awareness and aids in education

ndash Holds everyone accountable by allowing everyone to see what we are doing to prevent falls

ndash Will be placed in sign holders on the door of every room

bull Foot is kept in door of all patients who need to be helped to bathroom

ndash Privacy is maintained but not at expense of safety

ndash Applies to BSC as well

bull No more an arms-reach away from patients

ndash Requires education to ensure that patients know we have their best interests in mind

bull When called to assist other patients

ndash ldquoMy foot is in the doorrdquo is an acceptable indicator for the secretary to contact another staff member

ndash Secretary should call next staff member (RN or UT) and inform them that the other team member has their ldquofoot in the doorrdquo and another patient needs assistance

bull Goal

ndash Prevent falls during toileting

ndash Promote teamwork and communication amongst the staff

ndash Provide awareness to patients and families

bull Falls are a real issue and one of our biggest issues is that patients overestimate their abilities

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Product review

bull Footwear (PT pilot)

bull Gait Belts- all patient rooms to have one

bull Bed-side commodes- all patient rooms to have one

bull Walkers- all patient rooms to have one

bull Chair alarms- in process

bull Fall Mats- in process

bull Other

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

Next Stepsbull Spread the change

bull Keep pilot units on TST tool ndash sustain the change

bull Add additional units who are still challenged

bull Ongoing reporting

bull Ongoing improvements

bull Celebration Now amp futurehelliphelliphellip

55

QUESTIONS

BethNeidlingertmfhcorg

55

QUESTIONS

BethNeidlingertmfhcorg