Rapid Fire Team Presentation Template Name of Presenter: Sean Bisschop

Falls Facilitated Learning Series Name of Organization: Orillia Soldier’s Memorial Hospital Location of Facility: Orillia Ontario Number of Patients/Residents/Clients: 230 bed community hospital in Ontario’s cottage country; provide regional programs, as well as surgical and medical services to the residents of Simcoe County and Muskoka. Who We Are

Falls Facilitated Learning Series AIM To engage point-of-care staff and managers in a robust and sustainable fall prevention and harm reduction program.

Falls Facilitated Learning Series Team Members Ad hoc: point-of-service staff from all participating units Pauline Stewart, Program Manger – Soldiers’ 2 (Medicine) Michele Cook, Charge Nurse – Soldiers’ 2 (Medicine) Lesley Wesley, Program Manager – Harvie 2 (Surgery) Bonnie Masson & Brenda Prouty – Care Specialists Sylvia Naughton, Regional Integrated Falls Program Sean Bisschop, Quality & Patient Safety Coordinator, (Project Lead) Cheryl Harrison, VP Patient Service/CNE (Project Sponsor)

Falls Facilitated Learning Series Review Falls Change Ideas tested to date in your organization Changes Implemented within Organization Working/Not WorkingFacilitators/Barriers identified Feedback and monitoring on compliance with best practices processes Limited effectivenessB: competing demands and wasteful workflow processes (e.g., unruly paper charting) F: Data based huddles focus on practice compliance rates; staff problem solve together to reduce waste and increase compliance Patient mobility needs communication board UnknownF: Huddles surfaced this idea; undergoing PDSA Daily unit huddlesWorkingDaily data; shared problem solving; alignment

Falls Facilitated Learning Series Measures Falls / 1000 pt days% falls with harm One third of patients who fall at OSMH sustain at least minor/temporary harm

Falls Facilitated Learning Series Lessons Learned on Sustaining Falls Improvement Work during Action Period 1.“Falls program” left when previous project lead left OSMH 2.Poor compliance and monitoring of falls standard of care 3.Interventions cannot be reduced to a brief pick list 4.Falls prevention requires all disciplines 5.Assumptions: “people fall – there’s nothing else we can do”

Falls Facilitated Learning Series Wasteful workflows that limits time available for critical thinking Little root cause thinking – jumping to address symptoms Overly action oriented culture: “Let’s just do something – anything” Lack of quality improvement training for point-of-service staff and clinical leaders Changing staff assumptions Challenges to Sustaining Falls Improvement

Falls Facilitated Learning Series 6 Month Post FFLS Sustainability Plans for Falls Improvement Work Goal Description (What is AIM) Action (What STEPS are to be taken to achieve) Timeframe (When to be done by) Person Responsible Metrics: What is to be monitored to identify achievement Targeted ongoing training and new staff orientation Provide staff with contributing factors data (e.g., cognitive impairment, use of bed rails, room clutter, benzos) April 2012 Performance Excellence – Care Specialists % staff-trained % of falls with harm related to each unit's top two contributing factors Create quality improvement capacity in local teams to facilitate improve workflow Train multi-unit staff on Model for Improvement / Rapid cycle Improvement May 2012Sean Bisschop, Liz MurrayParticipation Improve use of best practice processes through unit-level monitoring of falls prevention & harm reduction best practices Spread to remaining three inpatient units June 2012Inpatient Program Managers % falls risk screening completed % “At Risk” Patients with a documented falls prevention & harm reduction plan

Falls Facilitated Learning Series 6 Month Post FFLS Sustainability Plan (continued) Goal Description (What is AIM) Action (What STEPS are to be taken to achieve) Timeframe (When to be done by) Person Responsible Metrics: What is to be monitored to identify achievement Leadership regularly using cascaded Lean Management System to monitor falls improvement work re: Quality Improvement Plan Create Falls focused Leader Standard Work that cascades from Board to bedside July 2012Board, CEO, VP Patient Care Services, Directors, Managers % of leaders completing Falls standard work as per their assigned frequency

Falls Facilitated Learning Series Name: Sean Bisschop Phone Number: x 3581 Contact Information