1. Fall Prevention Utilizing Six Sigma Methodologies to
Improve Patient Outcomes
Presented by: Virtua’s Fall Prevention Team

2. Tools For Driving Sustainable Change
What is Six Sigma?…
Methodology for achieving goals and objectives
Quantitative technique for problem solving
Comprehensive improvement process
Tools For Driving Sustainable Change

4. DMAIC Define Define Deliverables Develop Team Charter
Identify Project Critical to Quality (CTQ’s)
Define Process Map

5. DMAIC Team Charter Identify Project Team and Role assignments
Describe Project
Align with Strategic Imperatives
Delineate Timelines
Define Scope of Project
Identify Business Units
Analyze Constraints
Assess Project Benefits
Identify Project Goal
Evaluate Possible Barriers to Success

6. Opportunity Statement
DMAIC
Opportunity Statement
What first brought this opportunity to the attention of your business?
As of April 2008, CMS no longer provides reimbursement for treatments associated with patient falls. As a result of these falls, there is a potential for increased length of stay, increased mortality and a decrease in the quality of life.
What evidence do you have that it is really an opportunity worthy of attention?
Reducing the risk of patient harm from falls is one of the National Patient Safety Goals. Data analyzed shows erratic fluctuation in overall falls performance metrics, indicating no true reduction in patient falls across the system. Currently, Virtua has no standardized process for preventing, defining, or reporting patient falls.
What will happen if the business doesn't address this opportunity?
This initiative challenges hospitals to improve quality measures to improve patient outcomes. Failing to comply will have a negative impact on the culture of patient safety, public reputation and can result in inappropriate reimbursements.

7. Voice of the Customer (VOC)!
DMAIC
Voice of the Customer (VOC)!
VOC was captured to understand the problem
from the customers perspective

8. DMAIC
High Level Process Map

9. Not all stakeholders are supportive of the initiative…now what?
DMAIC
Stakeholder Analysis
Who
Strongly Opposed
Opposed
Neutral
Supportive
Strongly Supportive
COO X
Nursing Admin
Admissions Dir
Rec. Therapy
Diagnostics
Medical Director’s
RN’s, MST’s, CNA’s
Not all stakeholders are supportive of the initiative…now what?

10. DMAIC How it comes together ... At the end of define, we knew:
Why this project is important.
What business goals the project must achieve to be considered successful.
Who the key stakeholders are on the project.
What limitations have been placed on this project.
What key process is involved.
What are the customers’ needs and expectations.

11. Measure DMAIC Measure Deliverables Define performance metrics
Determine customer specifications and defects
Identify potential variables
Develop data collection plan
Establish process capability

12. What is the right “Y” to measure?
DMAIC
What is the right “Y” to measure?
VOC
Customer Need
Prioritized Project Y
Decrease patient falls
Effective and efficient bed alarms
Call bells answered in a timely manner
Standardized falls prevention education process
All hospital staff proactive with awareness of falls prevention
High risk patients identified accurately and placed on proper precautions
CTQ: Inpatient falls are below or equal to 3/1000 pt days
# of inpatient falls
Target: < or equal to 3/1000 pt days
CTQ: 100% accuracy in falls assessment on admission

13. Patient falls during hospital stay
DMAIC
Acute Care
Detailed Process Map
Patient falls during hospital stay

14. Cause and Effect Diagram
DMAIC
Initial
Cause and Effect Diagram

15. Data Collection DMAIC Developed data collection plan
Performed “gauge R and R”
Developed data collection guidelines
Determined acceptable sample size needed for chart review
Performed extensive chart review of all fall patients

16. DMAIC
How are we doing?
2004
2005
2006
2007
2008
In-patient falls (IPF)
737
617
673
726
717
IPF/1000 BCD (3)*
3.2
3.4
2.6
3.0
2.9 16

17. How it comes together ... DMAIC
At the end of measure, the team had/knew:
A list of potential variables
The critical input, process and output measures
The measurement system was accurate
What patterns were exhibited in the data
What the current process capability was

18. Analyze DMAIC Analyze Deliverables Identify variation sources
Establish performance objectives

19. Cause and Effect Diagram
DMAIC
Cause and Effect Diagram
C : Constant = something that doesn’t change
N : Noise = something that adds variability to our Y yet can’t be helped
X : X = a factor that drives our Y

20. DMAIC Impact/Effort Grid 1 2 4 3 7 5 6 Impact Effort
Nurses’ interpretation of the Morse Scale
Fall score day of fall
Medication within 6 hours of fall
Patient age
Location in room
Mental status the day of the fall
Orientation on the day of the fall
High/Low
High/High 1 2 4 3
Low/Low
Low/High 7 5 6
Impact
Effort

21. Information collected from chart reviews
What did we learn from Analyze?
Information collected from chart reviews
Inconsistencies in documentation
Fall score lowered day before fall: 38%
Neuro section of the nursing flow sheet discrepancies: 18%
Patient’s orientation on the day of fall was not reflected in the scoring of mental status on the Morse scale
No existing documentation on effectiveness of interventions
Confusion with the use and interpretation of the Morse Scale as an assessment tool
Inconsistent application of the intervention protocol resulted in patients falling multiple times during their hospital stay
Lack of documentation supporting changes made to the fall score
*Based on 154 charts reviewed

22. What did we learn from Analyze?
Change of shift
88% did not fall during shift change
Location of fall
82% fell near the bed
Day of the week
No statistical significance
Time of the day
LOS
Based on 154 charts reviewed
Continued

23. Survey results
77% of Nurses surveyed felt the Morse scale is not an effective assessment tool (Sample: 100)
42% of staff surveyed felt that *standard interventions are not effective (Sample:100)
36% of staff surveyed felt bed alarms are effective, but the response time is an issue (Sample:100)
60% are not aware of the amount of falls occurring on their units (Sample:124)
74% are aware of the falls safe program (Sample:124)
*two side rails, magenta (safety) bands

24. How it comes together ... DMAIC
By the end of the Analyze Phase, the team was able to show which causes they would focus on in the Improvement Phase by describing:
Which potential causes they identified
Which causes they decided to investigate and why
What data they collected to verify those causes
How the data was interpreted

25. Improve DMAIC Improve Deliverables A. Screen Potential Causes
*List of Vital Few “X’s”
B. Discover Variable Relationships
*Propose Solutions
C. Establish Operating Tolerances
*Pilot Solution

26. DMAIC Root Cause Analysis Factor Root Cause Proposed Solutions
No standard definitions for falls
Individual processes
Standardize falls definitions in alignment with NDNQI
Falls assessment tool
(i.e. Morse Scale)
Confusion with interpretation and use
Re-educate staff on the appropriate use. Investigate alternate user-friendly tools
No supporting data for changes made to the Morse scale
Inconsistencies in documentation
Implement best practice from LTC (post-fall assessment)
Missing information in Peminic
No fail safe hard stop enforcing required documentation
Upgrades made to Peminic to include hard stops to enforce required documentation
Inconsistencies in the use of fall interventions
No validation on effective interventions
Pilot improvements on unit with high risk patients and Implement strategic improvement template for consistency

27. Pre-pilot Activities DMAIC
The team followed a specific algorithm to complete task in preparation of the pilot.

28. Findings from Observations
DMAIC
Findings from Observations
No consistency in interventions used
Staff opinions varied on which interventions were in use
No standard process for rounding
Many employees were not aware of unit fall rates
Most employees had no knowledge of unit action plans
Nurses expressed difficulty interpreting Morse Scale
Patients identified at high risk were not easily found when reviewing pts charts
Fall precautions were not often followed on all patients identified at risk for falls
Staff could not easily identify patients at risk for falls

29. Standard Improvement Strategies for Pilot
DMAIC
Standard Improvement Strategies for Pilot
Educate staff on the process, importance of rounding, expectations and accountability
Educate nurses on the appropriate use of the Morse Scale
Consistency in initiating the “4 P’s” during hourly patient rounds (rounding with a purpose)
Post unit results in appropriate (visible) area as a constant reminder to staff: “how are we doing with patient falls” to increase staff awareness
Consistency in the use of standard interventions (magenta bands, two bed rails, personal items within reach, bed alarms (where applicable), falling star, chair alarms (where applicable)
Discuss patients at high risk during morning huddles to increase awareness
* 4 P’s = Pain, Position, Potty (Toileting) and Personal Items

30. Pilot Plan DMAIC Purpose:
Implement improvement strategies while monitoring performance and effectiveness of process and interventions to reduce preventable falls due to inconsistent practice
Where/Who:
2 nursing units identified with a high volume of patient falls (4N- Marlton, 4NE Memorial)
4 Members of the fall prevention team would work with staff to implement improvement strategies, making adjustments as needed
Staff would be surveyed on the perception of the current practice
Timelines:
3/15/10-5/17/10
Debrief Sessions:
Bi-weekly starting: 3/31/10 (Wednesday’s)

31. Pilot Plan- continued Procedures:
New procedures documented in SOP format
Other materials needed and instructions were developed
Staffing:
Utilizing existing staffing
Fall prevention core team would be available for consultation purposes
Stakeholders:
Extensive information about pilot was communicated to all (appropriate) key stakeholders.
All involved in the pilot were updated and educated accordingly.
Measurements:
See attached data collection plan to monitor key indicators.
Methods/tools developed to document what works, what doesn’t and who
would respond to unanticipated problems.

32. Metrics Page for Discrete Data
Result!
DMAIC
Metrics Page for Discrete Data
4NE-Memorial
Project Y
Target
Pre-pilot performance
(1st Quarter ’10)
Post –pilot Performance
(July ‘10)
(Aug ‘10)
# of all patient falls
3.85- fall rate
10 falls
3.66- fall rate
1 fall
1.03- fall rate
3 falls
TBD-fall rate
4N-Marlton
Project Y
Target
Pre-pilot performance
(1st Quarter ’10)
Post –pilot Performance
(July ‘10)
(Aug ‘10)
# of all patient falls
3.46- fall rate
10 falls
4.11-fall rate
3 falls
4.57-fall rate
2 falls
2.88-fall rate

33. FMEA DMAIC FMEA was completed and recommended actions included:
Implementing rounding with a purpose
Standardizing system for accountability and follow-through
Documenting factual narrative description of the event
Utilizing post falls assessment form
Discussing falls patients during interdisciplinary rounds
Including Pharmacy in interdisciplinary rounds once a week

34. Improve Fall Prevention DMAIC
Prioritizing the Variables to achieve Six Sigma!
Rounding with a Purpose: Audit tool and SOP’s, Badge Buddies, 4P’s, PCT rounding expectations (with and without clock). Falls will be standing item on unit based council agenda.
Post Falls Assessment: Requesting all elements to be available in Peminic.
Model under development.
Interdisciplinary Rounds: Daily goal sheet and shift report, encouraged to ask “what level of risk is patient?” instead of “Is patient at risk?”. Mandatory standard use of falling star intervention.
Staff Awareness: Daily and weekly monitoring tool. Falls banner to increase staff awareness.
Fall Education: Redesigned falls (online) education. Fall simulation developed for clinical orientation. Education developed for clinical and non-clinical support service departments
DMAIC

35. Next Steps for Control DMAIC
Inform organizational leaders of the changes made to the process
Develop tools needed to sustain improvement (Control plan, SOP’s, Virtual Tool Box, Informational share point sites, etc.)
Communicate changes made to the process to key stakeholders Virtua wide
Educate key stakeholders on the process Virtua wide
Roll out and implementation of improvement strategies Virtua Wide

36. Reducing variation to achieve 6 sigma one defect at a time!
Questions?
Reducing variation to achieve 6 sigma one defect at a time!