Evercare Quality Improvement Awards Falls Reduction Program

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Evercare Quality Improvement AwardsFalls
Reduction Program

• Susan E. Harris, CRA, ADC, LNHA
• Assistant Executive Director
• Daughters of Israel
• West Orange, New Jersey

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Faculty Disclosures

• Ms. Harris has disclosed that she has no relevant
  financial relationship(s).

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Learning Objectives

• By the end of the session, participants will be
  able to
• Objective 1 Understand the importance of
  multi-pronged interventions
• Objective 2 Understand the relationship between
  falls patterning and the decrease of falls
• Objective 3 Understand how program model can be
  replicated
• Objective 4 Understand how the falls reduction
  model can be utilized to affect change in other
  areas

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Facility Demographics

• Daughters of Israel
• West Orange, New Jersey
• Total of Beds 303
• 6 separate nursing units
• Inclusive of Alzheimers and End Stage Units
• Type of Ownership Non-Profit

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QI Project Falls Reduction Program

• Description of Problem- Falls were significantly
  higher than others in country, region, state
• Additional compounding problems
• Falls Quality Indicator at 91st Percentile
• Fall Rate 13.34 Industry standard 4.16
• Based on historical performance trends
• Objective Develop a Performance Improvement
  team to reduce resident falls by 10 annually
• Per study published by L. Rubenstein, et al, in
  materials distributed by CMS at a QI training
  seminar, Baltimore, MD, May 2000

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Project Timeline

• Project began May 1999
• Falls committee met twice weekly, then weekly
• Reported to CQI weekly
• Currently audits reported at CQI
• Planning Implementation
• Core of program developed over 4 years
• Various components added after that time
• When did project end?
• The reduction of falls is an ongoing process
• Monitoring, evaluation and CQI reporting
  continues today

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QI Planning Implementation

• Leadership
• Falls Sub-committee of members included staff
  close to the problem
• Team Work
• Team analyzed falls and determined what could be
  done to reduce them
• Data collection tools developed
• Communication
• Project introduced through care plan team
  meetings in-service education
• Results communicated to staff through
• Team meetings
• In-service education
• Posted QI studies

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Falls Sub-Committee

• DON
• Charge nurse
• Floor nurse
• Nursing assistants
• In-service coordinator
• MDS coordinator
• Activities staff
• Alzheimers Unit Director

• Physical therapist
• Social worker
• Dietician
• Medical Director
• Administrator
• Quality Assurance Director

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Falls Reduction ProgramIssues Encountered

• Tried falling leaf program briefly but too much
  was involved
• Tried developing a definition of what is a fall
  which didnt make any difference in what we were
  looking to accomplish

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Tools Used to Affect Change

• Computerized falls tracking system to identify
• Unit
• Time of fall
• Ambulatory status
• Use of side rails
• Use of restraining device
• Any injury incurred
• Staff involved
• Shift
• Expanded to look at other relationships with
  falls

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Tools Used to Affect Change

• Data on the patterning of falls
• Developed a weighted falls risk assessment at
  specific score CP required
• Policies and Procedures for Falls Reduction
  Program
• Changed incident report to better collect needed
  data
• Back page included list of investigation points
  to cover
• Today divided into 3 columns to improve data
  collections and understanding
• Falls Care Plan Book interventions listed by
  reason for fall
• Created Falls Tracking System
• Staff Education
• Falls Investigators
• QI audits of falls care plans and changes made to
  them per fall
• Incentive programs for units with the lowest
  number of falls monthly

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Facility Expenses

• The cost to us to reduce falls is minimal
• 1500 covered
• educational seminars,
• travel to seminars
• Planning and implementation for all staff
  involved approximately 654 hours per year

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Resident Outcomes

• Prior to Program
• Falls QI 91st to 95th percentile
• Fall Rate 13.34
• Average of 1119 falls annually

• Today 2008
• Falls QI 37th percentile
• Fall Rate 4.16
• Average of 398 falls annually

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Regulatory Outcomes

• No deficiencies for falls
• Surveyors not looking as hard in this area
• Falls QI is low
• Compliance with regulatory codes has increased

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Improved Quality of Service Outcomes

• In the first 4 years of this program dropped
• our fall rate by 59.2
• Staff follow-up for care plans and intervention
  changes went from 0 accuracy to 95 accuracy
• Exceeded 10 goal
• Restraint use has not increased
• Fall related fractures has decreased
• Met national benchmark

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Enhanced Staff Performance Outcomes

• Improvement on
• Investigation of falls
• Understanding patterning/causal factors
• Trained to pay attention to observable facts
  surrounding a fall
• Immediate response to care plan for updates
• Understanding when to change or add interventions
• Understand importance of immediate intervention
• Care Plans no longer state will not fall ,
  Will not have any injury
• Retain personhood
• Activities are crucial
• Good communication with families in regard to a
  fall

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Improved Organization, Management Structure and
Systems Outcomes

• Entire process changed centralized at CQI to
  decentralized on units
• Fall Management is a priority for everyone
• Chair and bed alarms are overused or misused
  changes in intervention use
• Weekend supervisor now begins investigation at
  the time the fall occurred
• All shifts trained on falls prevention
• Nursing assistants held accountable for falls
  interventions
• All CP and CNA CP updated at every fall
• Interventions in place earlier at admission,
  readmission, unit or room change
• Response at one fall or to high risk assessment
  score
• No longer document care plan remains same
  change what isnt working
• Starts prior to admission
• Tracking system used for falls carried over to
  skin tears and bruises
• Investigation process now used to investigate
  abuse allegations

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Financial Outcomes

• Average hospital charge for fall related injury
  11,800.70 (Nurse Practitioner, March 2002)
• Decreased rate of emergency admissions to
  hospital
• Most recent Evercare rate 77 admissions per
  1000 member years one of lowest in country
• QI New Fractures declined from 67th percentile in
  2002 to 38th percentile in 2007
• Results in less need for post fracture care

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Closing Thoughts

• Replication of Model inexpensive to set up
  easy to implement mostly requires staff buy in
  and understanding that it is a priority for all
• Lessons Learned It is not any one intervention
  that made a difference but instead the use of a
  multi-pronged attack of the problem and using
  multiple interventions at one time.
• Insights
• Not all falls can be prevented must also look at
  what can be done to minimize severity of injury
• Questions?