Next Steps AIM Statement Run Chart

Falls Reduction
Palmdale Regional Medical Center
Palmdale, CA
November, 2014
AIM Statement
Next Steps
Run Chart
Reduce Falls with Injury from 2011
baseline by 40% by December 2014.
• Gait belts to be kept on units for all staff use.
• Reinforce falls program at our Skills FairSeptember through November.
(Baseline = 2.15, AIM = 1.29 by 12/14.)
2014 YTD Performance: 0.1
A
Interventions
B C
(A) Interventions:
• Weekly meetings to drill down on all falls that
occurred during the previous week.
Data Source: Comprehensive Data System-HRET as of 09-09-2014
• Refreshed Stop Sign Program (originally started
in 2012).
• Posters placed in patient rooms. Addresses 6
elements:
• Identifies that the patient is at risk for falls.
Lessons Learned
• Call staff for any spill.
• Keep meetings non-punitive.
• Nurses remain in the room during toileting.
• Staff buy-in criteria.
• All equipment to be in reach of patient.
• Consistency, and reinforcement prevents backsliding.
• Use of assistive devices. (walker etc).
• Practice monitoring change.
• Rounding using scripting for toileting using active
vs. passive verbiage.
(D) Interventions:
• Post fall huddles initiated involving all staff caring
for patient.
(E) Interventions:
• Twice daily “patient safe handling” assessments
completed in Cerner. Tasks assigned to staff
every shift.
Team Members
• Chief Nursing Officer: Pat McClendon, MSN,
DNP
• Wear yellow non-skid socks.
(C) Interventions:
• Analyze fall data post CNA reduction 11/2013
(for statistical relevance).
• Create Break Room erasable posters
indicating how many days it has been since
our last fall.
(B) Interventions:
• Non-punitive and collaborative approach.
E
• Identify champions- Charge Nurses and MD’s
to join team.
• Facility wide email sent out daily indicating how
many days it has been since last fall, including
location.
• All involved staff invited to join.
D
• Analyze data at our 2 year mark (4/2015)
using statistical tools.
• Falls seem to occur due to toileting, and during change of
shift.
Resources
• HQI Falls Harm Elimination Toolkit is available on the HQI
website at hqinstitute.org < Tools and Resources.
• Questions: Contact Mahsa Farahani, Project Manager, HQI
at 916-552-7521, email mfarahani@hqinstitute.org.
• QA Director: Suzette Creighton, MA,
CPHRM, CPHQ, HACP
• Telemetry Director: Will Morrell-Stinson, RN,
BSN, CCRN
• Med-Surgical Director: Cindy Damboise, RN,
MSN, MHA, CCRN, PCCN
• Education/Joint & Spine Director: Daisy
Dorotheo, RN, BSN, MHA, ONC
• Physical Therapy Director: Myra Sylvestre,
CEAS
• Pharmacy Director: Dr. David Choi, PharmD
• Quality Analyst: Mary Siemantel, RN