1. First, Do No Harm Falls work Karen O’Keeffe Clinical Lead Presentation 7 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC

2. Northern Region Charter – Our Direction

3. Phasing of Implementation

4. First, Do No Harm Issues –We currently harm around 13% of people who enter our hospitals, many from preventable hospital acquired infections and falls. –Evidence shows that certain interventions, if systematically applied, will save lives, prevent harm to patients, save money, free up capacity and improve productivity. Actions Stock-take current activity Provide information for baselines Define terms, methodology, baseline for : Falls causing harm Pressure Injuries CLABS Transfers of care Patient ID Medication Safety Review : 50 most recent deaths Global Trigger Tool WDHB & ADHB Resource Toolkits

5. FDNH Key Areas Falls – reduce harm Pressure injuries – reduce harm Global trigger tools 50 death review Medication safety Transfer of care CLAB - national

6. FDNH Falls Focus Developing an understanding of the issues How to do this with a campaign focus Initial workshop – early engagement Expert group to establish measures: Adopted IHI Model for Improvement “Collaborative” approach model

7. Current Data Processes Linked to our 3 key aims –Reduction of harm from falls by 20% –Reduction of PI by 20% –Reduction of CLAB by 40% (national project) Developed by expert group Acute care and ARRC representation.

8. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Langley, et al. AIM MEASURES IDEAS WILL IDEAS EXECUTION

9. What is a Collaborative? Brings together groups of practitioners to work in a structured way to improve aspects of the quality of their service. Involves meetings to learn about: best practice in the area chosen quality methods change ideas share their experiences of making changes in local settings. Ovretreit et al. (2002)

10. First, Do No Harm Falls/PI Collaborative

11. Falls Data Review of monthly incident reports Agreed operational definitions Fall rates per 1000 bed days DHBs have provide year worth of base line data Ongoing monthly reporting (see Regional falls / pressure injuries Agreed operational definition s)

15. Combined data

16. Falls and PI Learning Session

18. Lessons learnt (Don’ts) Don’t present it solely a nursing problem! Don’t judge quality of care on crude falls rates, or panic if there is an increase in one area over a month or two – falls data can be easily skewed. Don’t focus on falls prevention at the expense of autonomy and rehabilitation. Don’t panic if falls rates are slow to drop over the first few years – there are no quick fixes for something this complex, and this often represents better reporting. Don’t forget real falls prevention interventions are what are what are important – not checklists and “box ticking.” Don’t benchmark – especially not serious harm falls! Northern Region Health Plan First, Do No Harm

19. Dos.. Do get accurate data (not easy!) Do focus interventions on those at most risk of harm should they fall (ABC) – Age, Bone density, AntiCoagulation Do post updates to results regularly and prominently – works best in a localised manner! Do build actions into processes that already work – for example assessment tools into admission packages or care plans. Do try to be resilient – there are doubters and detractors everywhere. It would be very easy to give up at times! Do learn from others, including the doubters and detractors! www.patientsafetyfirst.nhs.uk

20. Why Do Collaboratives work? Networked community effects Effective, horizontal pathways –Supported by the Model –Connected by the Model Forms a community (Learning Sessions) Reframes a social problem Owned by teams/ frontline staff/sectors

21. What have we learned? There is limited use of robust improvement methodology. Need to build capacity and capability The value of an Improvement Advisor The use of measurement for improvement –(few vital measures – dashboard) Challenges of gaining and keeping engagement

22. Going Forward Supporting teams during “action” periods Further building of capacity and capability Improving understanding of value and use of measures Facilitate the sharing of learning and resources Exploring STOPP /START medication