Falls Reduction Palmdale Regional Medical Center Palmdale, CA November, 2014 AIM Statement Next Steps Run Chart Reduce Falls with Injury from 2011 baseline by 40% by December 2014. • Gait belts to be kept on units for all staff use. • Reinforce falls program at our Skills FairSeptember through November. (Baseline = 2.15, AIM = 1.29 by 12/14.) 2014 YTD Performance: 0.1 A Interventions B C (A) Interventions: • Weekly meetings to drill down on all falls that occurred during the previous week. Data Source: Comprehensive Data System-HRET as of 09-09-2014 • Refreshed Stop Sign Program (originally started in 2012). • Posters placed in patient rooms. Addresses 6 elements: • Identifies that the patient is at risk for falls. Lessons Learned • Call staff for any spill. • Keep meetings non-punitive. • Nurses remain in the room during toileting. • Staff buy-in criteria. • All equipment to be in reach of patient. • Consistency, and reinforcement prevents backsliding. • Use of assistive devices. (walker etc). • Practice monitoring change. • Rounding using scripting for toileting using active vs. passive verbiage. (D) Interventions: • Post fall huddles initiated involving all staff caring for patient. (E) Interventions: • Twice daily “patient safe handling” assessments completed in Cerner. Tasks assigned to staff every shift. Team Members • Chief Nursing Officer: Pat McClendon, MSN, DNP • Wear yellow non-skid socks. (C) Interventions: • Analyze fall data post CNA reduction 11/2013 (for statistical relevance). • Create Break Room erasable posters indicating how many days it has been since our last fall. (B) Interventions: • Non-punitive and collaborative approach. E • Identify champions- Charge Nurses and MD’s to join team. • Facility wide email sent out daily indicating how many days it has been since last fall, including location. • All involved staff invited to join. D • Analyze data at our 2 year mark (4/2015) using statistical tools. • Falls seem to occur due to toileting, and during change of shift. Resources • HQI Falls Harm Elimination Toolkit is available on the HQI website at hqinstitute.org < Tools and Resources. • Questions: Contact Mahsa Farahani, Project Manager, HQI at 916-552-7521, email [email protected]. • QA Director: Suzette Creighton, MA, CPHRM, CPHQ, HACP • Telemetry Director: Will Morrell-Stinson, RN, BSN, CCRN • Med-Surgical Director: Cindy Damboise, RN, MSN, MHA, CCRN, PCCN • Education/Joint & Spine Director: Daisy Dorotheo, RN, BSN, MHA, ONC • Physical Therapy Director: Myra Sylvestre, CEAS • Pharmacy Director: Dr. David Choi, PharmD • Quality Analyst: Mary Siemantel, RN