1. © 2012 Virginia Mason Medical Center The Power of Patient & Family Engagement: Falls University Joanie Ching, RN, MN, CPHQ Administrative Director Hospital Quality & Safety

2. © 2012 Virginia Mason Medical Center 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

3. © 2012 Virginia Mason Medical Center

4. 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 learning and innovation Innovation We create an extraordinary patient experience Service We relentlessly pursue the highest quality outcomes of care Quality Vision To be the Quality Leader and transform health care Mission To improve the health and well-being of the patients we serve Values Teamwork | Integrity | Excellence | Service Strategies Virginia Mason Team Medicine SM Foundational Elements Patient Strong Economics Responsible Governance EducationVirginia Mason Foundation Integrated Information Systems Research Virginia Mason Production System Presented at Washington State Hospital Association Safe Table, 2/20/2013

5. © 2012 Virginia Mason Medical Center 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 Presented at Washington State Hospital Association Safe Table, 2/20/2013

6. 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

7. © 2012 Virginia Mason Medical Center Prior to Falls University Presented at Washington State Hospital Association Safe Table, 2/20/2013

8. © 2012 Virginia Mason Medical Center At Falls University Presented at Washington State Hospital Association Safe Table, 2/20/2013

9. © 2012 Virginia Mason Medical Center Falls University: Results-Oriented Study Observation & Develop a New Vision DO ACT PLAN CHECK Awareness- A Change In Thinking Observe and develop a new vision Rapid Implementation – Give it a try DO ACT PLAN STUDY Study the results Equipment SCD (Stow and go)PonischilWEP Fall Prevention Devices Yellow Fall Prevention Toolkit Falls CollabWEP Fall Prevention Devices Self-releasing, velcro belts Streifel, Brune, Barnes, MarottaWE P Family or Support Members Roles and Responsibilities Heinricher, O'ConnorWE P Family or Support Members Agreements Heinricher, O'ConnorWE P Family or Support Members Education Heinricher, O'ConnorWE P Staff Communication Fall Risk Assessment Falls CollabWEI Staff Communication Repeat Fallers All Mgr/DirWEI ToiletingHourly Rounding All Mgr/DirMEI ToiletingNever alone on commode All Mgr/DirMEM Planning Implementing Monitoring Presented at Washington State Hospital Association Safe Table, 2/20/2013

10. © 2012 Virginia Mason Medical Center 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 Presented at Washington State Hospital Association Safe Table, 2/20/2013

11. © 2012 Virginia Mason Medical Center 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 Presented at Washington State Hospital Association Safe Table, 2/20/2013

12. © 2012 Virginia Mason Medical Center Unattended Falls: Psycho-social Root Causes r/t Toileting 1/3: Don’t use call light 1/3: Left alone on toilet/commode 1/5: slip on way to BR Remainder: trip over clothing, SCDs or fumble/lose balance Presented at Washington State Hospital Association Safe Table, 2/20/2013

13. © 2012 Virginia Mason Medical Center Values Conflict Patient autonomy Privacy with toileting Duty of care to all –v- high-risk Presented at Washington State Hospital Association Safe Table, 2/20/2013

14. © 2012 Virginia Mason Medical Center Variation STANDARDIZATION Improvement Without standards, there can be no improvement. Presented at Washington State Hospital Association Safe Table, 2/20/2013

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16. © 2012 Virginia Mason Medical Center 13 of 35 points Presented at Washington State Hospital Association Safe Table, 2/20/2013

17. © 2012 Virginia Mason Medical Center Bundle for Highest Risk Group JH >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 Presented at Washington State Hospital Association Safe Table, 2/20/2013

18. © 2012 Virginia Mason Medical Center How would we know? We told everyone. We assumed they were all doing the bundle. Presented at Washington State Hospital Association Safe Table, 2/20/2013

19. © 2012 Virginia Mason Medical Center 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 Presented at Washington State Hospital Association Safe Table, 2/20/2013

20. Fall Prevention Audit Tool A B C I T 123123 Presented at Washington State Hospital Association Safe Table, 2/20/2013

21. © 2012 Virginia Mason Medical Center But We Told Them to … Purposeful Rounding Fall Intervention Strategies OCTOBER Toileting Safety ComfortSafetyComfort A B CIT 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-IMC5 2 21 CCU715 6 1 L7 PACE5 2 1 2 11 L81 0 0 RHU L103 2 1 Jones 112 11 11 L11 L12 L145 00000000000 L150 L162 2 L174 1 311 totals 42 41912 2 753 2%21%2%5%0%5%0% 17%12%7% defect metrics Presented at Washington State Hospital Association Safe Table, 2/20/2013

22. © 2012 Virginia Mason Medical Center 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 Presented at Washington State Hospital Association Safe Table, 2/20/2013

23. © 2012 Virginia Mason Medical Center “This is not the same person I’ve known.” -- A Family Member Presented at Washington State Hospital Association Safe Table, 2/20/2013

24. © 2012 Virginia Mason Medical Center Engaging Family Members Presented at Washington State Hospital Association Safe Table, 2/20/2013

25. © 2012 Virginia Mason Medical Center Ideas from Family Members Presented at Washington State Hospital Association Safe Table, 2/20/2013

26. © 2012 Virginia Mason Medical Center 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 Presented at Washington State Hospital Association Safe Table, 2/20/2013

27. © 2012 Virginia Mason Medical Center 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 ↓ Presented at Washington State Hospital Association Safe Table, 2/20/2013