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Enhancing Hospital Patient Safety Programs Using Key Tools Contract No.: HHSA290201200017I Task Order No. 2

Falls Prevention Learning Network 1 Webinar 4 Meeting Summary – November 18, 2015

Agency for Healthcare Research and Quality (AHRQ)

Enhancing Patient Safety – AHRQ Fall Prevention Program Implementation Sharing Webinars #4

November 18, 2015

Two presentations at the fourth AHRQ Fall Prevention Webinar on Nov. 18, 2015, focused on staff and leadership engagement. Melissa Hiscock and Judith DelMonte presented on behalf of Roswell Park Cancer Institute in Buffalo, NY. Then David McMillan presented second on behalf of Broward Health North in Deerfield Beach, FL. This was followed by a round-robin style of sharing from each of the hospitals participating in the AHRQ Falls Prevention Program. Each hospital shared one or more strategies that they use to engage staff and leadership in their hospitals.

PRESENTATION 1

Roswell’s Story – Involving the Hospital Board

Melissa Hiscock (Core Team Lead) stated the hospital joined the AHRQ project in May 2015. The QI

specialist came in June to do the onsite education. About that time, the AHRQ project was included in a

report to board members. In July, the CNO briefly introduced the AHRQ project at the quarterly board

meeting, and it sparked interest from board member Dr. Thomas Stewart, who is well known in the

wound care community.



“… It’s a blessing to us, and

amazing,” Melissa stated. “Not

everyone has access to someone like

him.”

She noted that Dr. Stewart comes to

the weekly meetings, is an active

member, wants to in-service the

staff, and helps us in any way he can.

“It seems very simple, and we are

very fortunate, but that’s how we

got our institute’s board involved,”

she stated.

Senior Leadership Presentation and Project

Charter

Judith stated that once Dr. Stewart came

aboard, the project team presented its “project charter” to the Institute’s Quality Committee, which

meets monthly and has five board members. Staff members who attend the monthly meeting include

the chief medical officer, chief operating officer, chief nursing officer, five physicians, and the vice

presidents of Quality, Managed Care, Clinical Research, Risk Management, Lab Medicine, and Pharmacy,

as well as departmental directors, Quality staff, and the patient safety officer.

Judith stated the project charter included a description of:

The AHRQ project and how the hospital was using the AHRQ toolkits to implement best

practices at the hospital



Critical success factors via the team’s metrics and overall goal, which is to decrease rate of

hospital-acquired pressure ulcers that are stage 2 and above. The team also shared other

metrics for the best practice tools.

The core team members, which included Melissa; Judith herself, who is the nursing quality

analyst that does all the data for the department of nursing; and the nurse bedside leaders.

Judith stated the team did not include all the subject matter experts, because the team has

about 25 people.

The SharePoint Web site, which is how the team posts all the data for the staff and board, and

contains all the materials for the project, meeting minutes, AHRQ tools, implementation items,

action plans, etc. Judith stated the Web site ensures they are all on the same page.

The Project Charter Close-Up and Action Plan



“The board members were really impressed that we really are grounded in keeping up with our goals,

and that we had actually set dates, and that we were meeting a lot of the goals, and that we were really

trying to make progress as part of this team,” Judith noted.

Uncompleted Components of the Action Plan

The second part of the action plan are things the team hasn’t done all the way, which is a lot of the IT

implementation. This got the board’s attention, because there’s a lot of IT issues all the time around the

hospital. With the board’s engagement, the team hopes it can push many of these things forward,

because they’ve been kind of standing out there for a while.



Incomplete Components of the Action Plan

The slide to the right presents data that shows the progress of the pilot units since starting the project. There are three pilot units: ICU, leukemia lymphoma unit (6 West), and medical surgery unit (7 East). Judith stated these units had the highest rate of pressure ulcers, noting the team wants to make sure that everyone is aware of the data so they can see where the hospital stands at any given time.



Rates and Cost

The slide to the right

grabbed the

attention of the

whole committee,

because when

putting the cost

along with the

measure, then it gets

everybody’s

attention, Judith

stated.

With CMS, anything

that’s above a stage

3 or greater, the

hospital is not

getting paid for. She

stated they ran the

hospital’s pressure ulcer numbers, with each costing $43,000 (the national average cost) for every

inpatient pressure ulcer that was stage 3 or above. Judith stated the team wanted to send the message

that driving down rates means driving down costs.

“When they see over a million dollars—even though it’s estimated—and we’re almost at $700,000, it

really gets their attention,” Judith stated, adding it gives them incentives to get on board with the

project and support efforts to decrease pressure ulcer rates.

Unit Quality Boards

The image to the right

shows the three pilot

units’ unit quality

boards, which are

updated with the

latest data when

there’s new

information. Patients,

families, and staff can

see the boards. If

anyone has questions

or ideas about the

board, the nurse

bedside leaders can

answer them or

Melissa.



Summary

Judith stated that the big takeaway from all of this is that using the internal intranet (SharePoint) to

organize the information for the project has worked very well. Everyone is on the same page, and at any

given time, people can see where we are—including leaders.

She stated that adding a finance person to the team was a big help because right now staff are going

through the codes. They are making sure pressure ulcers are coded on admission and appropriately, that

staff are on the same page as the WOC team—because they might have one case that they are calling a

pressure ulcer on admission but the coders call a hospital-acquired pressure ulcer.

Additionally, Judith stated they’ve engaged the board and senior leaders so they know what’s going on.



PRESENTATION 2

David McMillian stated that Broward Health North has 409 beds. The focus the AHRQ project is on the

hospital’s NeuroMedical ICU, and measures for that department will start being implemented in two

other in-house ICUs by the end of the month.

Starting Out

David stated the first thing

they did as a group was add

monthly meetings with the

CNO, because managers all

have meetings with a C

Suite, which is whoever

they report to on a monthly

basis, and they decided to

start sharing the AHRQ

project with them, the

requirements, and what the

process was.

“When we actually did the

pre-assessment tools with

our facility, we found many

opportunities,” David

stated. “One of the greatest

was that we did so much education for nursing, but did not do that for the education of radiology,

transporters, and so many other people who touch the patient.”

David stated staff realized they needed to provide education for others, and that’s why the AHRQ

assessment tools were so valuable for the hospital. He added that when he found this downfall, the

Hospital Acquired Pressure Ulcer Committee and AHRQ project committee decided to share the same



assessment tools with all the other committees in-house, which led to those tools being used by CAUTI,

SSI, and a speak-up campaign to trend for similar issues.

These items were presented at the Quality Council to the C Suite with a plan to correct all the

opportunities for improvement.

Education Gap

At this point, the hospital

realized there was a big

educational gap, and the C

Suite became involved

because it felt that

something different was

being offered to solve

problems. The C suite

responded well to the

AHRQ initiative and toolkits,

which has now impacted

every committee in the

building. This has led to the

standardization of all the

committees with all of

them now using the AHRQ

initiative tools.

As a result, a quick meeting, called a rapid cycle improvement, convenes weekly at the Thursday

management huddle at which C Suite attends and implements immediate interventions. David stated

this was put in because there would be a fall out in a unit, and there were lessons for everyone to learn.

He stated that all of this relates to the patients, with a focus on creating no harms to patients. This

engages staff and C Suite more than using numbers and projections.

“Our goal is to cause no harm to patients,” David stated, adding this has led to the 2015 Patient Safety

Guide.

Patient Safety Guide

David stated the guide (pictured on next page) comes out of using the AHRQ toolkit. Every person within

the building—even those who serve food—had to go through this education. That’s nearly 1,100

employees, he noted. Things addressed included how to keep patients from:

Getting a bloodstream infection

Getting a CAUTI

Getting pressure ulcers/bed sores

Falling



David stated that a “Speak Up” campaign has been created to improve communication. The hospital

used a circus theme, and the training offered popcorn. People responded well, he stated, noting: “We

like to have fun while we learn.” This is important when it comes to ensuring it sticks.

Education will be instituted at least every 3 months with managers in all the departments through the

education department and then safety education every 6 months to all staff. “When you have a big push

to make an improvement, you seem to do great for the first 6 months to a year, and then it kind of falls

off,” he stated.

Feedback

Feedback from the departments was positive. They are glad they were educated, and the hospital as a

whole found it educational, David stated. The C Suite didn’t know many of the interventions that are

conducted for pressure ulcers, falls, etc. When numbers are reviewed in the Thursday morning huddles

and Quality meetings, leaders now know what staff are dealing with patients, how it’s supposed to be

done, and this has made them much more savvy in the questions they ask the nurse managers in

providing excellent care for the patient.



Staff feedback that was

given to the C Suite has

been great as well, David

stated. For example, EVS

has said they could help

with Foley maintenance by

informing nurses when the

Foley bag should be

drained. Additionally, many

other non-clinical people

found it informational and

felt they were more

empowered to help the

patients.

“We even had a situation

last week where a security

guard was making rounds,”

David stated. “He saw one

of the Foley bags on the floor and notified the staff, and they were able to get it up off the floor,

because the patient had knocked it off while sitting up on the bedside. … It’s definitely a huge thing that

has affected our whole hospital.”

In the MICU, it experienced three to four events every month on average before implementation. In

August and September, there was one incident between the two months.

“We have had very few events from an average of three or four a month,” David stated. “And now that

we’re rolling out to ICU as a whole, I definitely see a big decrease in our harm events. Of course, no one

wants to harm a patient.”

As a whole hospital system, from last calendar year to this calendar year, Broward Health North went

from 58 to 28 harmful events.

“Definitely, the patient care at Broward Health North has benefited tremendously, and the staff on

every level from nursing to EVS and even to our security know what they need to do and how to help

nursing and the hospital cut down these harm events. We’d like to say thank you to AHRQ committee

and all the tools we’ve shared with everyone. So thank you.”



Round Robin – AHRQ Fall Prevention Hospital Strategies to Engage Staff and Leadership

Hospital Strategies to Engage Staff/Leaders

Good Samaritan Hospital San Jose, CA Bedsize: 474 Pilot Units: Medical, Rehab

Use Team STEPPS approach.

Fall prevention is now a standing agenda item on the Patient Safety Committee, which staff nurses attend.

Have policy of transparency with prior events.

Investigate what they find in huddles.

Madonna Rehabilitation Hospital Lincoln, NE Acute Rehab Beds: 48-50 Pilot Unit: Acute Rehab

Set goals for acute rehab: o RN, LPN, NA Annual Evaluation Goal: Total number of patient falls that

occurred due to failure to follow proper procedures as a result of employee disregard for risks, based on the most recent 12-month period to date.

o Nurse Therapist/Supervisor Annual Evaluation Goal: Decrease patient falls with greater than minor injury to 5.0% or less as measured by the Acute Rehab Quality Score Card.

Have quarterly staff meetings to share rates and interventions that work and don’t work. Discuss how to better meet goals.

Report rates to Patient Safety and Quality Committee, Med Exec Team, Admin Team, and Board.

Good Shepherd Medical Center Longview, TX Bedsize: 425 Pilot Units: Rehab, Medical, Cardiac IMC

To engage senior leaders:

Make quarterly presentations to Quality Council (made up of Board members, senior leadership, physicians, and department leaders). Present fall data, project initiatives, and help and resources needed to move forward. Provides a good forum to address barriers.

To engage staff:

Use “Days Since Last Fall” programs. Set unit goals, such as 30 days without a fall. Provide rewards (pizza, cupcakes) for reaching goals.

Units post their fall rates on a board in their own unique way.

Broadlawns Medical Center Des Moines, IA Bedsize: 100 Pilot Units: Med/Surg

Use shared governance approach.

Involve and empower frontline staff in most levels of decision-making, including workgroups, committees, and councils.

Fall prevention team (primarily composed of frontline staff) drive most of the discussion and changes. Leadership has more of a facilitator role.

Staff compliance and ability to embrace change more effective when presented by their peers, with leadership support.

Mayo Clinic Health System—Franciscan Healthcare LaCrosse, WI Bedsize: 150 Pilot Unit: Medical

Standardized Performance Board documents.

Set goal: to reduce falls with injury by reducing falls to less than 2.06 falls per 1000 patient days.

Update run chart quarterly.

Try to get frontline staff to own the process. For example, ICU charge RNs update the falls calendar at the end of each D12/N12 shift by placing a red or green “X” in their shift slot and hand off this information during huddle.

Update falls calendars monthly and post on unit boards.

Discuss the previous month’s calendar results at the next Falls meeting.

Run charts are not always meaningful to frontline staff. So they need to be explained better.

Senior leadership knows what to expect on each department’s Performance Board in their Quality/Safety column.

McDonough District Hospital Macomb, IL Bedsize: 48

Created an electronic audit tool to ease the burden of data collection.

Unit Champions carry an IPad in rooms to conduct live audits. Not someone outside of unit coming in; it’s a peer.

This will allow us to analyze the data quickly and efficiently, and help us prioritize opportunities.



Hospital Strategies to Engage Staff/Leaders

Pilot Units: Acute Care Med/Surg

Anderson Regional Medical Center Meridian, MS Bedsize: 260 Acute Care, 148 Post-Acute Care Pilot Units: 2 East (Med/Surg and Pediatrics) Telemetry and CCU Stepdown

Starting Dec. 1, will display poster boards that are divided into “working” teams.

Each quarter reflects teams for day shift rotations and night shift rotations.

Put tally marks in appropriate boxes.

Allows unit falls to be displayed in a more timely fashion.

Creates transparency and friendly competition.

VA Hudson Valley Health Care System Wappingers Falls & Montrose, NY Bedsize: CLC- 94, Medical Unit -27, Mental Health - 63 Pilot Units: E-2- Medical Unit Home of The Heroes Community Living Center–residents have cognitive loss

During the intentional rounding lean project implementation, we utilized a teaching methodology that required staff members to teach each other at shift change.

The CORE team trained the day shift.

The day shift fall champion trained the evening shift.

The evening shift was to train the night shift and then night shift to train days.

There were some schedule conflicts. So staff that were not trained on the night shift or not working those days were trained by the fall champions on additional days.

UMass Memorial Medical Center

Use a shared leadership model.

Give meeting minutes to leadership.

Interdisciplinary team produce monthly flier (case scenarios, Morse Scale, medications, etc.). Staff discusses flier.

Interdisciplinary team attends meetings.

Present fall rates and initiatives to all patient and family care councils (Quality and Patient Safety, Clinical Practice, etc.).

Steward Good Samaritan Medical Center Brockton, MA Bedsize: 267 Pilot Units: 3B (Cardiac/Telemetry), 4A (Med/Surg), & 4BH (Senior Behavioral Health)

Report all falls to Nurse Practice Council (reps from all units) and Quality and Safety.

Have standardized reporting system.

Senior Leadership makes safety rounds in pilot units and throughout hospital

Doing prevalence-based line data collection.

Looking into posters and marketing tools for patients, patients’ family, and staff.

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