© 2012 Virginia Mason Medical Center The Power of Patient & Family Engagement: Falls University Joanie Ching, RN, MN, CPHQ Administrative Director Hospital.

© 2012 Virginia Mason Medical Center© 2012 Virginia Mason Medical Center

The Power of Patient & Family Engagement: Falls University

Joanie Ching, RN, MN, CPHQ

Administrative Director Hospital

Quality & Safety


Objectives

• Review our structured learning approach to patient falls

• Share our progress from measuring outcomes reliability of processes

• Highlight patient and family engagement through delirium work

Presented at Washington State Hospital Association Safe Table, 2/20/2013


2013 Organizational Goals

Quality and Safety: Care Delivery Innovations• Delivering Patient-Centered Coordinated Primary Care• Optimizing Care Transitions• Smoothing Patient Flow• Eliminate Healthcare Associated Infections• Glycemic Control• Prevention of Hospital Associated Delirium

Service: Patient Experience• Integration of the Patient Experience

Strong Economics• Growth

Integrated I.S.: Technology and Care Delivery Partnerships • Realizing the Potential of Our Electronic Health Record • Update the Enterprise Orders & Documentation Framework • Ambulatory CPOE• Measuring and Improving our Results

Quality, Safety, Service, People, Innovation• Respect for People

People: Team Engagement• Transformational Leadership• Organizational Training & Education

We attract and develop

the best team

People

We foster a culture of learningand innovation

Innovation

We create anextraordinary

patient experience

Service

We relentlessly pursue the

highest quality outcomes of care

Quality

VisionTo be the Quality Leader

and transform health care

MissionTo improve the health and

well-being of the patients we serve

Values

Teamwork | Integrity | Excellence | Service

Strategies

Virginia Mason Team MedicineSM Foundational Elements

Patient

Strong Economics

ResponsibleGovernance

Education Virginia MasonFoundation

IntegratedInformation

Systems

Research

Virginia Mason Production System



Stopping the Line: “Falling Star”

• Leadership commits to “drop & run”• After Action Review

Staff involved, Patient, Family members• Every fall → Falls University (founded 3/09)

What happened?

Every fall stops the line


Stopping the Line

“… when production stops everyone is forced to solve the problem immediately. So team members have to think, and through thinking team members grow and become better team members and people.”

-- Teruyuki Minoura Toyota Motors, NA


Prior to Falls UniversityDirector/Manager Pre-work (prior to the Falls University)

Yes No Comment Review PSA report Cerner review Repeat fall? Consistency of fall scores? History of delirium? CAM Score (+ or - ) MAR Review—any meds contributed to the fall, time of

administration?

Fall documentation Any risk for injury (Age, Bones, Coagulation, Surgery)

Fall risk precautions in place? Universal? High Risk? Bed/chair alarm Toileting schedule Hourly rounding Patient Assignment in Zones Hand-off RN/PCT integration



At Falls University

Discussion at the Falls University (1 minute presentation) Yes No Comment

Bring a copy of the PSA report

Give brief patient history What happened?? (From staff & patient interview)

Cause(s) of the fall? (Root cause analysis)

Nursing foundational elements in place?? (Cell work, Huddle, Handoff , RN/PCT integration)

Were appropriate fall precautions in place?

What could have been done differently?

Type of fall? 1) Accidental (Slip/Trip) 2) Unanticipated Physiological (Seizure, TIA) 3) Anticipated Physiological

Corrective Action Plans (CAPs) Degree of CAPs* Me We All

Learnings



Falls University: Results-Oriented Study

Observation &Develop aNew Vision

DODOACTACT

PLANPLAN

CHECKCHECK

Awareness-A ChangeIn Thinking

Observe and develop a new vision

RapidImplementation – Give it a try

DODOACTACT

PLANPLAN

STUDYSTUDYStudy the results

Equipment SCD (Stow and go) Ponischil WE PFall Prevention

DevicesYellow Fall Prevention

Toolkit Falls Collab WE P

Fall Prevention Devices Self-releasing, velcro belts

Streifel, Brune, Barnes, Marotta WE

P

Family or Support Members Roles and Responsibilities Heinricher,

O'Connor WEP

Family or Support Members Agreements Heinricher,

O'Connor WEP

Family or Support Members Education Heinricher,

O'Connor WEP

Staff Communication Fall Risk Assessment Falls Collab WE I

Staff Communication Repeat Fallers All Mgr/Dir WE I

Toileting Hourly Rounding All Mgr/Dir ME IToileting Never alone on commode All Mgr/Dir ME M

Planning

Implementing

Monitoring



Lack of Evidence-Base

“ …in acute hospitals, no single interventions are fully supported by current evidence, and that multifactorial interventions may reduce falls by 18-31%.”

Oliver, et al, 2010



Increasing Patient Surveillance

Geographic assignments

Huddles every shift

In room handoffs

RN:PCT integration

Hourly rounds by caregivers

Documentation near the patient

Daily Leader rounds

People Link Boards updated & staff huddles monthly

through Foundational Elements



Unattended Falls: Psycho-social Root Causes r/t Toileting

1/3: Don’t use call light1/3: Left alone on toilet/commode

1/5: slip on way to BRRemainder: trip over clothing, SCDs or fumble/lose balance



Values Conflict

• Patient autonomy• Privacy with toileting• Duty of care to all –v-

high-risk



Variation STANDARDIZATION Improvement

Without standards, there can be no improvement.


T



13 of 35 points



Bundle for Highest Risk GroupJH >13 and/or risk of injury (e.g. fracture risk or bleeding risk)• Mandatory gait belt• Mandatory bed and chair alarms**• Consider low bed and floor mats• Remain within arms-length of toileting patient• Level of Assist:

PARTIAL ASSIST- Keep hands on patient OR MAX ASSIST- 2 People + Lift

• Evaluate need for Constant Care Companion

**unless pt has met criteria for alarm discontinuance



How would we know?

We told everyone.We assumed they were all doing the bundle.



Genchi Genbutsu

• “It’s all lies” unless you see it• Go to where the action is• Look at the process• Know your people and let them know you• Vulnerability is OK


Fall Prevention Audit ToolR

oo

m #

Pat

ien

t (L

ast

nam

e)

JH s

core

- >

13 a

nd

his

tory

(p

re-s

cree

ned

)

# o

f p

atie

nts

on

Iso

lati

on

p

reca

uti

on

s

# o

f p

atie

nts

wit

h C

CC

Ask

: to

ilet

ing

E

vid

ence

of

toil

etin

g (

I/O

rec

ord

, A

sk

Pt.

)

Bed

al

arm

on

(g

reen

lig

ht

on

?)

Ch

air

Ala

rm o

n (

gre

en

lig

ht

on

?)

If N

I an

swer

ed i

n l

ast

2 co

lum

ns,

wer

e re

aso

ns

full

y d

ocu

men

ted

?

Bed

lo

w a

nd

lo

cked

Ch

eck

bed

su

rfac

e h

eel

zon

e

Pat

ien

t ch

ecke

d f

or

com

fort

Item

s ar

e w

ith

in r

each

Pat

ien

t kn

ow

s ti

me

of

nex

t vi

sit

(las

t ro

un

d c

ross

ed o

ff

on

bo

ard

?)

Corr

ect

Leve

l-of-

Ass

ist

Sign

age

Post

ed

Gai

t be

lt

Co

mm

en

ts

Y / N Y / N / NI Y / N / NI Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N / NI




















A B C I T

123



But We Told Them to … Purposeful Rounding

Fall Intervention Strategies

OCTOBER Toileting Safety Comfort Safety Comfort

A B C I T

Unit

number of patients audited

# of pts on precautions

# of patients with a

sitter/CCC

# of pts NOT asked

about toileting

# of times bed alarm NOT on when it should

have been

# of times Chair Alarm

NOT on

# of times NI for

bed/chair alarm NOT properly

documented

# of times bed was NOT low

and locked

# of times bed surface heel zone was NOT checked

# of times patient was

NOT checked for

comfort

# of times items were NOT within

reach

# of times the time of next visit

was unknown

# of times the correct Level-

of-Assist signage was NOT posted

# of times gait belt was

absent Action plan

ED

L9-IMC 5 2 2 1

CCU7 15 6 1

L7 PACE 5 2 1 2 1 1

L8 1 0 0

RHU

L10 3 2 1

Jones 11 2 1 1 1 1

L11

L12

L14 5 0 0 0 0 0 0 0 0 0 0 0

L15 0

L16 2 2

L17 4 1

3 1 1

totals 42 4 1 9 1 2 2 7 5 3

2% 21% 2% 5% 0% 5% 0% 0% 17% 12% 7%

defect metrics



Falls University 201: Delirium

• 10-31% of hospitalized patients, more likely to occur in the elderly population

• Falls, functional decline, extended LOS, nursing home placement, cognitive deficits & mortality

• Constant Care Companions (CCCs) can provide supervision



“This is not the same person I’ve known.”

-- A Family Member



Engaging Family Members



Ideas from Family Members



Acute Care of the Elderly PDSA

• A quality improvement efforts to decrease constant care companion use on two inpatient units

• Focus: Prevention and treatment of delirium• Education was provided to staff• Family members invited to participate in care• Patient rounds with multidisciplinary plan of care review• Fall rates, CCC use in hrs, and CCC costs were measured before

and after the intervention



Results

• Education was provided to 100% of staff• CCC use decreased by 4,048 hrs in one

year• Cost savings over $73,000• Fall rates and falls with injury ↓


© 2012 Virginia Mason Medical Center The Power of Patient & Family Engagement: Falls University Joanie Ching, RN, MN, CPHQ Administrative Director Hospital.

Documents

patient flow

na slide

people people

patient experience integration

results quality

best team people

thinking team members

better team members