South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

West of England Academic Health Science Network - launch

Preventing Harm from Patient Falls

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Improving Safety in MentalHealth Collaborative

South of England

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Patient story

Improving Safety in MentalHealth Collaborative

South of England

“I needed to go to the toilet. I couldn’t find the call bell. I kept calling out for help. Eventually someone came but they went to get a commode and I couldn’t wait. I know I shouldn’t have tried to get out without help. I should have just gone on the sheets in the bed and then I wouldn’t have broken my hip.”

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Situation

• Within 18 months:–Reduce the total number of inpatient

falls by 10%–Reduce the number of serious falls by

20%–Reduce the number of recurrent falls by

20%

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Background

• 2 large hospital sites• Over 9000 staff• Over 1000 beds• Over 65s is the fastest growing group in population

of local area• Change in Culture amongst staff

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Strategic Falls Prevention Groupfrom Ward to Board

• Wide membership of engaged staff– Matrons, nursing, Medical, Therapy, Pharmacy,

Facilities, Audit, Patients

• Executive Sponsor• Pragmatic frontline actions to reduce falls risk on

wards• Quality Improvement methodology in developing

new tools at ward level

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

PDSA Testing Ramps

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APS

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DATA

FEEDBACK

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STAFF:

Complia

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with fo

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D SP A

Cycle 1A: new falls risk assessment form – 1 patient

Cycle 1B: Form modified to link directly with key interventions to prevent falls

Cycle 1D: test with 1, 3 then 5 nurses

Cycle 1C: modify form with RAG risk levels

Cycle 1E: Test form on all patients

Process Change PDSA: Testing falls prevention bundle

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Falls risk assessment

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Bed safety rail assessment

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Scheduled checking

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

After falls care

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Visual cues for staff

Involving all staff members and visitors

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Posters

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

How did we do?

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Weekly e-audit tool

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Pull from neighbouring wards

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Falls Rate per 1000 bed days from January 2011 to August 2013 Pilot Ward

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Falls rate per 1000 bed days April 2011 to August 2013 Spread Ward

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Trust-wide Falls Rate per 1000 bed days from April 2012 to August 2013

27

19

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Trust-wide Recurrent falls from April 2012 to January 2013

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

What worked

• Working with teams on the ward to test and influence the development of interventions that worked for their patients

• Regular huddles to keep up the momentum• Resisting “Spray and Pray”• Leadership at every level

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Our achievements

• Implementation of action-focused bundle across 2 large sites across 18 months with sustained improvement

• Involved all members of staff in the hospital from Switchboard to phloebotomists

• We have reduced serious harm from falls in our Trust by 30%

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Next challenges

• Focus on acute confusion assessment of patients• Improvement work on medical assessment of falls

by junior doctors• Measuring blood pressure accurately to identify

postural hypotension• New hospital!

South West Quality and Patient Safety Improvement Programme

(Safer Care South West)

Recommendation

• Identify a pilot area with engaged staff

• Ensure you have baseline data for process measures before testing

• Get the right team together

• Set up measurement system early

• Don’t spread until you have reliable and sustained improvement