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South West Quality and Patient Safety Improvement Programme (Safer Care South West) West of England Academic Health Science Network - launch Preventing.

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Presentation on theme: "South West Quality and Patient Safety Improvement Programme (Safer Care South West) West of England Academic Health Science Network - launch Preventing."— Presentation transcript:

1 South West Quality and Patient Safety Improvement Programme (Safer Care South West) West of England Academic Health Science Network - launch Preventing Harm from Patient Falls South West Quality and Patient Safety Improvement Programme (Safer Care South West) Improving Safety in Mental Health Collaborative South of England

2 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Patient story Improving Safety in Mental Health Collaborative South of England I needed to go to the toilet. I couldnt find the call bell. I kept calling out for help. Eventually someone came but they went to get a commode and I couldnt wait. I know I shouldnt have tried to get out without help. I should have just gone on the sheets in the bed and then I wouldnt have broken my hip.

3 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Situation Within 18 months: –Reduce the total number of inpatient falls by 10% –Reduce the number of serious falls by 20% –Reduce the number of recurrent falls by 20%

4 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Background 2 large hospital sites Over 9000 staff Over 1000 beds Over 65s is the fastest growing group in population of local area Change in Culture amongst staff

5 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Strategic Falls Prevention Group from Ward to Board Wide membership of engaged staff –Matrons, nursing, Medical, Therapy, Pharmacy, Facilities, Audit, Patients Executive Sponsor Pragmatic frontline actions to reduce falls risk on wards Quality Improvement methodology in developing new tools at ward level

6 South West Quality and Patient Safety Improvement Programme (Safer Care South West) PDSA Testing Ramps AP SD A P S D AP SD D S P A DATA FEEDBACK TO FRONTLINE STAFF: Compliance with form completion D S P A Cycle 1A: new falls risk assessment form – 1 patient Cycle 1B: Form modified to link directly with key interventions to prevent falls Cycle 1D: test with 1, 3 then 5 nurses Cycle 1C: modify form with RAG risk levels Cycle 1E: Test form on all patients Process Change PDSA: Testing falls prevention bundle

7 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Falls risk assessment

8 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Bed safety rail assessment

9 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Scheduled checking

10 South West Quality and Patient Safety Improvement Programme (Safer Care South West) After falls care

11 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Visual cues for staff Involving all staff members and visitors

12 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Posters

13 South West Quality and Patient Safety Improvement Programme (Safer Care South West) How did we do?

14 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Weekly e-audit tool

15 South West Quality and Patient Safety Improvement Programme (Safer Care South West)

16 South West Quality and Patient Safety Improvement Programme (Safer Care South West)

17 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Pull from neighbouring wards

18 South West Quality and Patient Safety Improvement Programme (Safer Care South West)

19 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Falls Rate per 1000 bed days from January 2011 to August 2013 Pilot Ward

20 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Falls rate per 1000 bed days April 2011 to August 2013 Spread Ward

21 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Trust-wide Falls Rate per 1000 bed days from April 2012 to August

22 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Trust-wide Recurrent falls from April 2012 to January 2013

23 South West Quality and Patient Safety Improvement Programme (Safer Care South West) What worked Working with teams on the ward to test and influence the development of interventions that worked for their patients Regular huddles to keep up the momentum Resisting Spray and Pray Leadership at every level

24 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Our achievements Implementation of action-focused bundle across 2 large sites across 18 months with sustained improvement Involved all members of staff in the hospital from Switchboard to phloebotomists We have reduced serious harm from falls in our Trust by 30%

25 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Next challenges Focus on acute confusion assessment of patients Improvement work on medical assessment of falls by junior doctors Measuring blood pressure accurately to identify postural hypotension New hospital!

26 South West Quality and Patient Safety Improvement Programme (Safer Care South West) Recommendation Identify a pilot area with engaged staff Ensure you have baseline data for process measures before testing Get the right team together Set up measurement system early Dont spread until you have reliable and sustained improvement


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