June 6, 2017
Story by Joanne Neilsen
Far fewer patients are falling and incident reporting is up thanks to a Falls Management Strategy developed by Unit 58 at South Health Campus (SHC) in Calgary — the recipient of this year’s President’s Excellence Award for Outstanding Achievement in Quality Improvement.
“Due to a higher risk and number of falls seen in SHC’s neurology patient group, the site’s Falls Safety Focus Group selected Unit 58 to participate in AHS’ 2014 Provincial Falls Risk Management Collaborative,” says Jodi Ploquin, South Health Campus Clinical Safety Leader Patient Safety. “We felt that if our unit with the highest fall rate could improve, there would be learning we could share to reduce patient falls across SHC."
Prior to the strategy, the unit was seeing around 20 falls per month, with 60 per cent of falls reported in AHS’ Reporting and Learning System (RLS) for patient safety. (RLS is an online system for reporting patient safety incidents with the goal of sharing, learning and improving.)
Today, that number has been reduced to six falls, with 100 per cent of incidents now reported in RLS.
“The strong leadership and team on Unit 58, has created the culture and enthusiasm required to embrace quality improvement and patient and family centred care,” says Lori Anderson, Senior Operating Officer, South Health Campus. “Their dedication and impressive outcomes are making an appreciable difference to patient safety and patient experiences, and both patient and staff satisfaction.”
At the outset, the unit set up a Falls Risk Management Working Group to identify what preventative tools they had in place and what tools they needed. As patients who fall once are most likely to do so again, the group reviewed the charts of patients who had a fall reported, to look for unreported falls. They also compared RLS reports with other AHS acute care neurosciences units.
They then developed a strategy and an algorithm tool to help identify the risk of falls, educate patients about the risks, apply universal falls precautions, create a post-fall assessment plan and submit an RLS report.
“At the project start, we were in a new hospital with a new team,” says Deana Obiso, Nurse Clinician, Unit 58 Inpatient Neurosciences. “We came from other hospitals, cities, and provinces. RLS was new to many of us. We focused on learning and were surprised at how quick and easy RLS was to use.”
Plonquin, in collaboration with the unit’s ‘Fall Prevention Champions’ highlighted the importance of RLS reporting through in-service training, Quality Touchpoints and ad hoc staff education.
“Our ‘Champions’ are passionate about quality improvement and make learning fun and not tedious,” said Obiso. “They always surprise me with their energy and creativity — they’re a big part of how we’ve built awareness and sustained results.”
Through ongoing theatrical skits, musical raps and special events with seasonal themes, the ‘champions’ continuously encourage and support falls-prevention. In April, they rolled about an Easter Eggstravaganza Cart and quizzed people. If an answer was missed, they took this opportunity to reiterate, re-educate and reinforce falls prevention in a fun and positive way – and everyone got a chocolate egg.
“I always say that in patient safety, we are ‘chasing zero’— and what’s exceptional about this team is that they’re committed to ‘the chase’ for the long term,” says Ploquin. “They have six active working groups now, and they each do their part to make things safer and better for patients.”
“Being nominated for a PEA award showcased the quality improvement culture we practise daily,” says Obiso. “We celebrate our improvements efforts and successes — our site and department leaders regularly join in. Their participation validates our work and inspires us.”
SHC has now adopted the strategy and standardized the REDuce Falls Algorithm; it’s customizable to patient populations and environments. Other units using the tool have also seen a reduction in falls and severity of harm.
“We were ecstatic to win and have our work validated by the organization and our CEO,” says Obiso. “Although quality improvement work feels ordinary for us, by winning this award, we realize that it’s extraordinary!”