Transcript Fall Prevention Data Collection - K-HEN

Fall Prevention
K-HEN Data Collection
& Submission
Dolores Hagan, RN BSN
K-HEN Education and Data Manager
August 2012
Objectives
• Review reporting requirements
• Review K-HEN recommended measures
• Review the specifications for monitoring
data (Inclusion and exclusion criteria)
• Discuss requirements for baseline data
• Define data entry and submission timeline
• Identify measures that may be pulled
from other systems where data is
currently being entered
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Reporting Requirements
• For each topic area chosen, hospitals are
required to submit data for at least
– One process measure AND
– One outcome measure
• Hospitals are strongly encouraged to
report on the K-HEN recommended
measures
• Additional outcome and/or process
measures may be selected and reported as
desired
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K-HEN Recommended Measures
• Purpose—standardize reporting on the same
measures across the state for robust
benchmarking capability
• Measures selected based on polling data from
the KHA Quality Conference in March 2012
• Have continued to evolve with your feedback
(Keep it coming! )
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HRET HEN Encyclopedia of Measures
• Lists all measures available in the CDS
• Defines the numerator and denominator for
each measure
• Provides a link to the source of the measure
• http://www.khen.com/Portals/16/Documents/HRET_HEN_
Encyclopedia_of_MeasuresV3.pdf
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Falls Prevention: Outcome Measure
• Preferred measure: #38 Falls with Injuries
(Minor or Greater) (NSC 4)
• Alternate measure: #37 Falls with or without
injury to the patient (NSC 3)
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# 38 Falls With Injury Criteria
• Numerator—Total number of patient falls of injury
level minor or greater (whether or not assisted b y a
staff member) by eligible hospital unit during the
calendar month X 1000.
Inclusions
– Falls with Fall Injury Level of ‘minor’ or greater, including
assisted and repeat falls with an injury level of minor or
greater
– Patient injury falls occurring while on an eligible reporting
unit
#38 Fall Reduction Criteria
• Denominator—Patient days by Type of Unit during
the calendar month
Inclusions
– Inpatients, short stay patients, observation patients, and same
day surgery patients who receive care on eligible inpatient units
for all or part of a day
– Adult critical care, step-down, medical, surgical, medical-surgical
combined, critical access and adult rehabilitation inpatient units
– Patients of any age on an eligible reporting unit are included in
the patient day count.
Exclusions
– Other unit types (e.g. pediatric, psychiatric, obstetrical, etc.)
Source: National Quality Forum
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# 37 Fall Definition
An unplanned decent to the floor (or extension
of the , e.g. trash can or other equipment)
with or without injury to the patient and
occurs on an eligible reporting nursin unit. All
types of falls are to be included whether thy
result from physiological reason (fainting) or
environmental reasons (slippery floor).
Include assisted falls – when a staff member
attempts to minimize the impact of the fall
Source: National Quality Forum
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#37 Fall Prevention Criteria
• Numerator—Total number of patient falls with or
without injury to the patient and whether or not
assisted by a staff member) by hospital Unit during
the month X 1000
– Inclusions: Patient falls occurring while on an eligible
reporting unit; assisted falls; repeat falls
– Exclusions: Falls by:
• Visitors; Students; Staff members;
• Falls by patients from eligible reporting unit, however
patient was not on the unit at the time of the fall
• Falls on other unit types (e.g. pediatric, psychiatric,
obstetrical, rehab, etc.)
Source: National Quality Forum
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#37 Fall Prevention Criteria
• Denominator—Patient days by hospital Unit
during the calendar month
Inclusions
– Inpatients, short stay patients, observation patients, and same day
surgery patients who receive care on eligible inpatient units for all or
part of a day
– Adult critical care, step-down, medical, surgical, medical-surgical
combined, critical access and adult rehabilitation inpatient units
– Patients of any age on an eligible reporting unit are included in the
patient day count.
Exclusions
– Other unit types (e.g. pediatric, psychiatric, obstetrical, etc.)
Source: National Quality Forum
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Patient Days Calculation
• Method 1 – Midnight census (least accurate)
• Method 2 – Midnight census plus Actual hours for Short
Stay Patients (Report short stay days separately and sum to obtain
patient days)
• Method 4 – Patient Days from actual hours (most
accurate) Information system that counts actual time
spent in the facility by each patient. Sum actual hours for
all patients and divide by 24
• Method 5 – Patient Days from Multiple Census reports.
Census is collected multiple times per day and averaged.
A sum of the daily average is calculated at the end of the
month
Source: National Quality Forum
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Fall Reduction: Process Measure
• Preferred Measure: #34 Percent fall risk
assessments completed within 24 hours of
admission
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# 34 Fall Reduction Process Measure Criteria
• Numerator—Number of patients with fall risk
assessment completed within 24 hours
– Fall risk assessment tool should at least include
assessment of the six areas assessed by the Morse
Fall Scale
•
•
•
•
•
•
History of falling
Secondary diagnosis
Ambulatory aid
IV/Heparin lock
Gait/Transferring
Mental status
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Baseline Data
• Only submitted one time
• For all topic areas except Readmissions:
– Baseline data is from 2011 prior to January 1, 2012
– May be the entire calendar year of 2011 or any other
period within the year (a month, a quarter, etc)
– Enter your specific period beginning and ending
dates
• Readmission Baseline Data
– Preferably CY 2011
– May use Jan – Jun 2012 if 2011 data is not available
• If no baseline data is available, do not enter anything for
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baseline—begin with monitoring data
Fall Reduction Data Entry
Complete baseline
data entry by
August 31!
• Data should be entered on a monthly basis as
much as possible
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Fall Reduction
2012 Monthly Data Entry Schedule
Monitoring Month
Data Entry Available
Data Entry Complete
January
Immediately
As soon as possible*
February
Immediately
As soon as possible*
March
Immediately
As soon as possible*
April
Immediately
As soon as possible*
May
Immediately
As soon as possible*
June
Immediately
As soon as possible*
July
August 1, 2012
August 31, 2012
August
September 1, 2012
September 30, 2012
September
October 1, 2012
October 31, 2012
October
November 1, 2012
November 30, 2012
November
December 1, 2012
December 31, 2012
December
January 1, 2013
January 31, 2013
*If data is available
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Comprehensive Data System (CDS)
• Link to HRET training webinar for CDS
located on K-HEN website under Data Page
• https://www.hretcds.org/Login.aspx
• Data coordinator receives initial login and
creates hospital’s users
– At least two data administrators
– As many data entry users as needed
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Measure Selection
• Review the K-HEN Recommended
Measures and the HRET Encyclopedia of
Measures
• Determine which measures you will report
Remember you MUST report on at least one
process and one outcome measure
per topic area selected
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Measure Enrollment
• Enroll in the measures that you are
reporting
• Select Admin  Measure Enrollment
– Select the topic area
– Select/deselect and save the measures that
you will be reporting on
– This will narrow your choices for data entry to
only those selected
– You may reselect those measures at a later
time if desired
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Data Collection & Entry
• Review the numerator and denominator
criteria for the measures selected
• Collect and compile the data
• Sign on to the CDS
– Select Data Entry tab
– Select the topic from the drop  Select Next
– Find the appropriate measure  Select Enter
Data
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Baseline Data Entry
• Defaults to the Baseline tab
• Enter the Measurement start and end dates  Select
‘Add’
• Under ‘Data Entry’ column, Select ‘Go’
• Was data collected for this measurement period? 
Select Yes or No
– If No, enter reason (e.g. data not available)
– If Yes, enter the numerator and denominator
– Select Save or Submit
• Save holds data in ‘temporary’ area and is not available for
reporting within the CDS
• Data may be edited by the hospital until it is submitted
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Monitoring Data Entry
• Select the Monitoring tab
• Under the Data Entry column, Select ‘Go’ for
the appropriate month
• Was data collected for this measurement
period?  Select Yes or No
• If No, enter reason (e.g. data not available)
• If Yes, enter the numerator and denominator
• Select Save or Submit
– ‘Save’ holds data in ‘temporary’ area and is available for
reporting within the CDS
– Data may be edited by the hospital until it is submitted
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Data Tidbits
• Each month should have data entered or a
reason it was not collected
• Additional training will be provided after data
has been entered and reporting is available
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Monthly Progress Report
•
•
•
•
Due to K-HEN by the 10th of each month
Use template provided
One report per topic area
Report template and sample complete
report located on K-HEN website (www.khen.com) under Tools and Resources
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Project Title: ______________________________
Hospital Name: ____________________________
Date: _____________
State: _____________
Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here>
Aim Statement
Aim?: (Including your How
Good and By When
statement)
Why is this project
important?:
Changes being Tested,
Implemented or Spread
(For each listed change,
indicate whether it is being
tested (T), Implemented (I)
or Spread (S))
Run Charts
Lessons Learned
(Make fonts large, title, labels, dates
and notes very simple on graphs
prior
to shrinking graphs. Should be able
to
fit 6-8 readable graphs here.
If no data are available for a particular
measures either create “empty” run
list
the name of the measure(s) to be
collected.)
(Enter summary here)
Recommendations and
Next Steps
• Enter summary here (what
do you need from Executive
Project Champion, Sponsor
at this time to move
project?)
• Recommendations
• Next steps for testing
Team Members
(Name of Project
Champion, Senior Leader
Sponsor & all other names
& roles)
© 2012 Institute for Healthcare Improvement
Sample Completed Report
Project Title: Reducing Acute Setting Falls Date: August 10, 2012
Hospital Name: Baptist Hospital Northeast State: Kentucky
Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) =1
Aim Statement
Run Charts
Lessons Learned
Decrease the number of
acute patient falls by 40% by
12/31/12.
•Importance of correctly
identifying patients
at risk for falls.
Why is this project important?
Maintaining patient safety by
reducing the risk of injury related
to falls will improve patient
outcomes.
•Importance of educating patient
and family on falls prevention.
•Importance of increasing
ancillary staff awareness and
empowering all staff to take
action in reducing falls.
Changes being
Tested, Implemented
or Spread
Recommendations
and Next Steps
Morning Safety Huddles which
include discussion of any recent
incident. (I)
•Work with other hospitals in
system to evaluate Falls Risk
Assessment Tool.
Interdisciplinary Falls Committee
meets monthly, led by Patient
Safety Officer, PSO. (I)
PSO to visit Departmental Staff
meetings to increase safety
awareness. (I)
Use of Call Don’t Fall tent cards (I)
Hourly Rounding with Intent (S)
•Continue Safety Huddles to
promptly identify lessons learned.
•PSO to empower all staff to take
action in reducing falls.
Team Members
Project Champion: Nancie Robertson, Hospital
Executive Champion: Karen Higdon, Team: Brenda
Johnson, Michelle Lynn, Angela Sandlin,
•Identify barriers and perceptions
of staff related to hourly rounding
with intent.
© 2012 Institute for Healthcare Improvement
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Project Assessment Scale
• http://www.khen.com/Portals/16/Documents/HRETHEN
ProjectAssessmentScale.pdf
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Homework
• Set up CDS users for your site
• Collect and enter baseline data by Aug 31
• Enter monitoring data for Jan - May 2012 as
available
• Enter monitoring data for Jul 2012 by Aug
31
• Complete July progress report by Aug 31
and email to [email protected]
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Questions
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