1. Summary of Action Period 1 TN Patient Safety Collaborative: Reducing Physical Restraints Learning Session 2 April 7, 8 & 9 th, 2009

2. When We Started Learning Session 1, October 2008 Overview of collaborative process Teams developed goals Teams learned how to report monthly progress

3. Share common goals Teach and learn from each other Provides systematic approach Why a Collaborative

4. Sample Aim Statement from a Senior Leader Report

5. To reduce restraint use to no more than 2% of our population within 60 days. This will be accomplished by an interdisciplinary team whose focus is to address falls and fall risk and also to develop individual care plans to meet each resident’s personal needs. Goals/AIM Statements

6. To reduce restraints to 10% or less within a six month period To reduce and maintain physical restraints to 2% or less in three months by assisting and evaluating the residents currently with restraints and implementing new measures to eliminate these interventions. Will decrease to 1% or less in six months (by April 2009) with the long term goal of being restraint free. Goals/AIM Statements, cont.

7. Collect monthly data from measurement strategy Restraint process and outcome measures Numerators and denominators entered into data tracking tool Approach

8. Data Tracking Tool This is a Required Outcome Measure Data Location: Restraint Log NumeratorDenominatorMeasure GOAL Monitoring Month Number of residents physically restrained on the LAST FRIDAY of the month Total number of residents in the census on the LAST FRIDAY of the month O3. Percent of residents who were physically restrained on LAST FRIDAY of the month # of Missed Opportunities INITIAL: 2% LONG TERM: 0% November- 0897512.00%9 2% December- 0887810.26%8 2% January-0997811.54%9 2% February-095796.33%5 2% March-096797.59%6 2% April-09 #N/A02% May-09 #N/A02% June-09 #N/A02% July-09 #N/A00% August-09 #N/A00% September-09 #N/A00% October-09 #N/A00% November-09 #N/A00% December-09 #N/A00% January-10 #N/A00%

9. Data tracking tool shows opportunities for interventions Interventions tried/tested through PDSA cycles PDSAs are reported on Senior Leader Report Senior Leader Report and data tracking tool submitted to QSource monthly Approach, cont.

10. Plan - What is the situation or problem? Do - What did I do about it? Study - Did it work? Act - Based on what I learned, what am I going to do now? Plan-Do-Study-Act (PDSA): What it Really Means

11. Plan-Do-Study-Act (PDSA): The Building Block for Change “That’s too complicated; I don’t have time for things like that.” “I’ve got patients to care for and situations to deal with.”

12. Curing PDSA Phobia It’s simple as… P I E

13. P lan I mplement E valuate

14. P lan: Identify the problem. What steps you will take to try to fix the problem? Different actions? New interventions? Different equipment?

15. I mplement: Put your plan into action. Test your interventions.

16. E valuate: Did your plan work? Yes? OK, what now? No? Why not? What else can we try? Your answers will lead you right back to…

17. Comparing PDSA with PIE PDSAPIEWhat it Means Plan What are we going to do? DoImplementPut the plan in motion StudyEvaluateDid the plan work? ActBased on what we learned, what will we do next?

18. Senior Leader Report IV. Brief Description of Key Changes (PDSA Cycles) Plan: Who What When Where Why? Do: What actually happened during the test? Study: What did the test data show? What did we learn? Act: Are we ready to implement this change? What will we need to do before the next test cycle? 1.Plan: Do: Study: Act: 2.Plan: Do: Study: Act: 3.Plan: Do: Study: Act: 4.Plan: Do: Study: Act:

19. Learning Session 2

20. Action Period 1: Activities Teleconference calls SLRs and tracking tools Onsite visit Weekly team meetings Distributed SLR newsletters Completed 2 PDSAs a week Discussion list serv

21. Action Period 1: Outcomes Teams test on a small scale Teams establish measurement system and begin to use data Teams begin to use other collaborative participants as resources

22. Challenges Time/staffing issues Computer skills Internet access Complex PDSAs Completing 2 PDSAs a week Documentation Inconsistent data collection

23. Measurement strategy Family and staff reluctance/opposition Knowledge Cost Perception and attitudes Challenges, cont.

24. Lessons Learned Education is key to change Creative innovative ideas Commitment One person can’t do it all Don’t assume a restraint is forever; conditions and situations change Easier to do things the ‘old way’

25. Obtain staff input to increase buy-in when changing the plan of care Address individual needs/strengths of the resident and re-evaluate for least restrictive It can be done! Lessons Learned, cont.

26. Increased activities, time in group settings, and ambulation are tremendously helpful during restraint reduction Involve all disciplines Diligence and reinforcement Make it fun Lessons Learned, cont.

27. Look at resident’s behavior to determine personal agenda and respond to resident needs New alternative devices must be tried under close staff supervision during a trial period with careful attention to resident circumstances Lessons Learned, cont.

28. Maintaining a restraint free facility is a daily battle requiring continual assessment and education Lessons Learned, cont.

29. Successes Increased sharing Success stories CNAs take more ownership Individualized care plans No restraints upon admission Using least restrictive device Reducing restraint usage Improving quality of life

30. O1. Proportion of residents physically restrained any time within two calendar days of admission

31. O2. Percent of residents with falls resulting in serious injury Group Average: 4.1% Goal: <10%

32. O3. Percent of residents who were physically restrained on LAST FRIDAY of the month Group Average: 7.2% Goal: 2%

33. P1. Proportion of residents physically restrained that received a re-evaluation to reduce or eliminate the restraint Group Average: 68.8% Goal: 100%

34. CMS Quality Measure Rate (Nursing Home Compare) Percent of long-stay residents who were physically restrained

35. QIES Quality Indicator Rate 11.1 Residents who were physically restrained

36. Failure is the opportunity to begin again more intelligently - Henry Ford

37. This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services. Contents do not necessarily reflect CMS policy. QSOURCE-TN-PS-2009-05 Summary of Action Period 1 TN Patient Safety Collaborative: Reducing Physical Restraints Learning Session 2 April 2009 Thank You!