Welcome to the

AHRQ Fall Prevention Program

Implementation Sharing Webinars

Sponsored by:

Agency for Healthcare Research and Quality (AHRQ)Hosted by:

The AFYA Team

(AFYA, Inc., ECRI Institute, Stratis Health)

August 19, 2015

Today’s Topics

• Welcome and AHRQ introduction

• Meet the AHRQ Fall Prevention Program project team

• About the Implementation Sharing Webinars

• Introduction of participating hospitals

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Webinar Tools for Interaction

• Raise your “hand” to contribute to the discussion or ask a question.

OR

• Use the CHAT panel.

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Welcome and Thank You

Joanne Robinson

AHRQ Task Leads

Janine Payne

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Greetings from AFYA

Michelle Tregear, AFYAProject Director

Gloria Stables, AFYASenior Curriculum Developer

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Quality Improvement Specialists

Marilyn Reierson

Stratis Health

Kelly O’Neill

Stratis Health

Barbara Rebold

ECRI Institute

Patricia Neumann

ECRI Institute

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Fall Prevention Experts

Pat QuigleyAssociate Director, VISN 8

Patient Safety CenterAssociate Chief for

Nursing Service/Research

Julia NeilyVeterans Health Administration

National Center for Patient Safety

Patricia DykesCenter for Patient Safety

Research and PracticeCenter for Nursing

ExcellenceBrigham and Women’s

Hospital

Cait WalshAccreditation Manager and Co-Director of Measuring to

Achieve Patient Safety —M.A.P.S.

Ronald Reagan UCLA Medical Center

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Aim of Project

To assist hospitals in implementing AHRQ’s fall prevention toolkit to help overcome the challenges associated with developing, implementing, and sustaining a fall prevention program.

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Implementation Sharing Webinars

Purpose

• Hear from national experts

• Collaborate and learn from your peers (other participating hospitals)

• Share successes and lessons learned

Topics

• Identified by YOU

• Grounded in best available evidence and research

Timing

• Monthly (3rd Wednesday at 3 p.m. ET)9

Why Collaborate?

• Shared goals

• Leverage resources

• Address similar barriers

• Problem solve together

• Learn from each other

• Identify system changes to address jointly

• Build relationships

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To Support Collaboration

• Listen to others

• Be respectful of things you hear

• Be open to learning new things (have a “learner’s mind”)

• Contribute and share

• Ask questions

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And now more about the hospitals participating in the Fall Prevention Program.

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Participating Hospitals: Size and Location

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Good Samaritan Hospital

San Jose, CABedsize: 474

Pilot Units: Medical, Rehab

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Good Samaritan Hospital

What we are proud of!• Development of a comprehensive fall prevention

policy• Developing an overhead paging identification

(Code Star) when a patient falls - basically an all hands on deck

• Post-fall huddles• Fall data is trending down; however, there are

periodic spikes• The real excitement is there have been no falls

with major injury in the last 6 months

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Madonna Rehabilitation Hospital

Lincoln, NEAcute Rehab Beds: 48-50

Pilot Unit: Acute Rehab

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Madonna Rehabilitation Hospital

What we are proud of!• Use of fall risk levels

• Interdisciplinary team approach

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Good Shepherd Medical Center

Longview, TXBedsize: 425

Pilot Units: Rehab, Medical, Cardiac IMC

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Good Shepherd Medical Center

What we are proud of!• Post-fall huddle

• Post-fall assessment documentation and tracking

Would like to hear more from other hospitals about:

• Personal/bed alarm usage/protocols

Becker’s Top “100 Great Community Hospital”

#1 in the Market for Medical Excellence in Overall Hospital Care and Overall Medical Care by CareChex® – a division of Comparion®

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Broadlawns Medical Center

Des Moines, IABedsize: 100

Pilot Units: Med/Surg

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Broadlawns Medical Center

What we are proud of!• Focus on processes to change

• Desire and willingness to improve

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Mayo Clinic Health System –

Franciscan Healthcare

LaCrosse, WIBedsize: 150

Pilot Unit: Medical

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• Community hospital with ~100 beds

• Southwest Wisconsin region of the Mayo Clinic Health System (which has 4 regions)

• Mayo Clinic Health System is part of the larger Mayo System – Rochester, Arizona, Florida and Waycross, Georgia

• Our biggest work as an organization right now is convergence in practice as we prepare for a common EHR in 2016

Mayo Clinic Health System –

Franciscan Healthcare

Mayo Clinic Health System –

Franciscan Healthcare

What we are proud of! • Re-organizing and broadening our Falls Committee to eventually

include a focus on Ambulatory, Hospital Outpatients, and Community Falls Prevention, as well as re-energizing our current primary focus of inpatient fall prevention strategies.

• Getting clear about what our Falls Committee to-do’s are and what our pilot unit and other department to-do’s are (we left our training session with 46 questions and ideas to consider along with the 3 opportunities our 18 participants each identified on that day - - yes, that’s a total of 71 - because some of the overzealous participants identified more than 3! Grand total of ideas to consider: 117! Meeting weekly to address the ones that we can and bringing the rest to the Falls Committee.

• Standardizing our Falls documents that are displayed on each department’s Performance Board, which serves as a visual display of our Lean Management System.

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McDonough District Hospital

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Macomb, ILBedsize: 48

Pilot Units: Acute Care Med/Surg

McDonough District Hospital

What we are proud of!• Control charts• Action plan

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Anderson Regional Medical Center

Meridian, MSBedsize: 260 Acute Care; 148 Post-Acute CarePilot Units: 2 East (Med/Surg and Pediatrics)

Telemetry and CCU Stepdown

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Anderson Regional Medical Center

• Ranked in the top 10% of U.S. hospitals for patient experience and stroke care

• Certified as a Primary Stroke Center by The Joint Commission, the American Heart Association, and the American Stroke Association

• Received the American College of Cardiology’s Silver Performance Achievement Award for 2015 - Anderson is one of only 91 hospitals nationwide to receive the honor

• Received five stars for quality from Healthgrades in care for stroke, hip fracture, and knee replacement

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Anderson Regional Medical Center

What we are proud of!• Post-fall huddles

• Integrated post-fall huddles into electronic incident reporting system

• Easier to extrapolate data and track trends

We hope to hear what is working well for other facilities and gain new perspectives on our current

procedures and processes.

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VA Hudson Valley Health Care System

Wappingers Falls & Montrose, NYBedsize: CLC- 94, Medical Unit -27 , Mental Health - 63

Pilot Units: E-2- Medical Unit, Home of The Heroes Community Living Center–residents

have cognitive loss

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VA Hudson Valley Health Care System

What we are proud of!• The systematic approach to

evaluating Fall Program, developing process map of present practice, and doinggap analyses

• Collaborative interdisciplinary approach to fall prevention—Patient Safety, QM, Nursing, PM&R, Medical Provider, Pharmacy, Education , Engineering

• Assessment of veterans at risk and implementing interventions to prevent falls

• Fall boards on inpatient homes/units

Fun Fact!

The Combined Core Team has over 100 years of service in the VHA System.

Castle Point Campus started as a TB hospital.

Montrose Campus was named after President Franklin D. Roosevelt, who toured the hospital while he was in office.

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What are the goals of the board?• To share real-time data on falls with all staff• To have frontline staff collect data on falls for their unit• To heighten staff awareness of falls for their unit

Our Fall Board

VA Hudson Valley Health Care System

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• Instituting a Lean project: “Improve Quality of Intentional Hourly Rounding Process on E2”

• If successful this project may: – Improve the quality of intentional hourly rounding

completed on E2– Reduce falls on E2– Improve patient safety – Improve quality of patient experience while on E2

• Key Metric: number of completed process measures observed in an hourly rounding observation

number of expected process measures for an hourly rounding observation

VA Hudson Valley Health Care System

Lean Project

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UMass Memorial Medical Center

Fall Prevention Program Implementation Team Members:Ellen Felkel-Brennan, Brian Brisbois, Donna Guillaume, Lindsay

Knight, Lynn D’Esmond, Mary Bonner

Worcester, MABedsize: 779

Pilot Units: 4 West, University Campus –Ortho/Trauma

South 2, Memorial Campus – Medical/Cardiac34

Umass Memorial Medical Center

Fall Knowledge Test

• Assess general staff knowledge (p.119)

• Academic approach

– Core Team reviewed the test

– Compared questions to our current fall program

– Adapted tool

• Excellent Response: 143 responses

- RNs, PCAs, PT/OT, LIPs

• Outcomes

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Umass Memorial Medical Center

What we are proud of!• Dedication of our core team

• Tracking days without a fall/Fall Calendar

• New white boards incorporating fall awareness

What we want to hear more about:• Enhancing culture towards fall prevention

• Specific action items for ongoing sustainability

• What has been successful with other organizations

• Early access to Evidence Based Practice regarding fall prevention

Fun FactChloe is an active member of our staff! She is very involved in Pet Therapy, especially with our elderly and pediatric patients.

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Steward Good Samaritan Medical Center

Brockton, MABedsize: 267

Pilot Units: 3B (Cardiac/Telemetry), 4A (Med/Surg), & 4BH (Senior Behavioral Health)

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Steward Good Samaritan Medical Center

What we are proud of!• Alignment of Fall Prevention

Policy and the Electronic Medical Record

• Incident Reporting System

Would like to hear more from other hospitals about:

• Managing patients with impulsive behaviors

Named Among the Top 20 Best Hospitals in Massachusetts by U.S. News & World Report

Fourth Time Recipient of “A” Safety Grade by The Leapfrog Group

Three-year Accreditation Renewal for our Cardiovascular Laboratory

Three-year accreditation in radiation oncology from the American College of Radiology (ACR)

Awarded Baby-Friendly® Hospital distinction by Baby-Friendly® USA

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“Never doubt that a small group

of thoughtful, committed citizens

can change the world. Indeed,

it is the only thing that ever has.”

-Margaret Mead

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Questions/Discussion

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