Transcript No Slide Title

Fall Prevention
Utilizing Six Sigma Methodologies to
Improve Patient Outcomes
Presented by: Virtua’s Fall Prevention Team
What is Six Sigma?…
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Methodology for achieving goals and
objectives
Quantitative technique for problem
solving
Comprehensive improvement process
Tools For Driving Sustainable Change
The DMAIC Methodology
... define the problem, clearly
and related to our customer...
...what are we measuring; know our
measure is good...
… look for root causes;
generate a prioritized list of
inputs...
... determine and confirm the
optimal solution ...
…be sure the problem
doesn’t come back...
DMAIC
Define
Define Deliverables
A. Develop Team Charter
B. Identify Project Critical to Quality (CTQ’s)
C. Define Process Map
DMAIC
Team Charter
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Identify Project Team and Role assignments
Describe Project
Align with Strategic Imperatives
Delineate Timelines
Define Scope of Project
Identify Business Units
Analyze Constraints
Assess Project Benefits
Identify Project Goal
Evaluate Possible Barriers to Success
DMAIC
Opportunity Statement

What first brought this opportunity to the attention of your business?
As of April 2008, CMS no longer provides reimbursement for treatments associated with
patient falls. As a result of these falls, there is a potential for increased length of stay,
increased mortality and a decrease in the quality of life.
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What evidence do you have that it is really an opportunity worthy of attention?
Reducing the risk of patient harm from falls is one of the National Patient Safety Goals. Data
analyzed shows erratic fluctuation in overall falls performance metrics, indicating no true
reduction in patient falls across the system. Currently, Virtua has no standardized process for
preventing, defining, or reporting patient falls.
What will happen if the business doesn't address this opportunity?
This initiative challenges hospitals to improve quality measures to improve patient outcomes.
Failing to comply will have a negative impact on the culture of patient safety, public
reputation and can result in inappropriate reimbursements.
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DMAIC
Voice of the Customer (VOC)!
VOC was captured to understand the problem
from the customers perspective
DMAIC
High Level Process Map
Patient Admitted
Receives falls
assessment
Patient Status
Identified
(High falls risk or
not)
Patient level of
cognizance
determined
Interventions put
into place
Communicate
patient status
Ongoing
Assessment
Patient
Discharged
DMAIC
Stakeholder Analysis
Who
Strongly
Opposed
Opposed
Neutral
Supportive
Strongly
Supportive
COO
X
Nursing Admin
X
Admissions Dir
X
Rec. Therapy
X
Diagnostics
X
Medical Director’s
X
RN’s, MST’s, CNA’s
X
0
Not all stakeholders are supportive of the initiative…now what?
DMAIC
How it comes together ...
At the end of define, we knew:
•Why this project is important.
•What business goals the project must achieve to be
considered successful.
•Who the key stakeholders are on the project.
•What limitations have been placed on this project.
•What key process is involved.
•What are the customers’ needs and expectations.
DMAIC
Measure
Measure Deliverables
A.
B.
C.
D.
E.
Define performance metrics
Determine customer specifications and defects
Identify potential variables
Develop data collection plan
Establish process capability
DMAIC
What is the right “Y” to
measure?
VOC
Customer Need
Prioritized Project Y
•Decrease patient falls
•Effective and efficient bed
alarms
•Call bells answered in a
timely manner
•Standardized falls
prevention education process
•All hospital staff proactive
with awareness of falls
prevention
•High risk patients identified
accurately and placed on
proper precautions
CTQ: Inpatient falls are
below or equal to 3/1000
pt days
CTQ: 100% accuracy in
falls assessment on
admission
# of inpatient falls
Target: < or equal
to 3/1000 pt days
Acute Care
DMAIC
Detailed Process Map
Patient admitted
receives fall
assessment
At Risk?
Yes
Magenta band
placed on patient
Other
preventions
(where available)
put into place
Daily & PRN
documentation
on nursing flow
sheet
Education/POC
documentation
Sign placed in
room for patient
to call for help
Two side rails up.
Bed in low
position.
Brake on.
Golden rod form
completed
Phone, call light
within reach
No
No further action
taken
Shift to Shift
report
Ongoing
reassessment
Patient
discharged
Patient falls during hospital stay
Pt. falls during
admission
VST assessment
Call H.P to see
patient
Complete
occurrence
report
Schedule testing
(if necessary)
Patient injured?
No
Yes
Call family
immediately
Call attending
Physician
Redo Morse
Scale
Change POC
Call family (at a
reasonable hour)
DMAIC
Initial
Cause and Effect Diagram
Process
Assess. Tool
Staff unaware
Lack of hourly
Of change in status
rounding
Family failure to
Notify staff on
Untimely D/C
departure
Planning
Misinterpretation of
Assessment tool
Morse scale:
Bed rest =0
Only 1 tool used in
Assessing pt risk
Assessment criteria
Communication
No standardized
process
Decrease in non-slip
footwear given to
Pts.
Checking for recalled
items
Infrequent obs. Lack of comm
On transfers
Of pat.
No daily review
For mod risk pts.
Failure to comm. Pt.
Status accurately (Family)
No communication to pt
About risk
No communication to family
About risk
Lack of comm. btwn
staff
Patient Falls
Unaware of
Morse scale
Category rules
Lack of chart reviews
Failure to notify staff of
Departure from pt.
room
Physicians
Residents unplugging
Bed alarms
Placement of teleMonitors (block call bells)
Poor lighting
Tripping hazards
Inside pt room
Misplacement of
Bed pad
Mislabeled call
lights
Clutter in rooms
Environment/Other
Lack of knowledge
Of appropriate equip
usage
Review annual
competency
Tracking
competency
Education
Lack of safety awareness
No knowledge of falls
Prevention program
DMAIC
Data Collection
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Developed data collection plan
Performed “gauge R and R”
Developed data collection guidelines
Determined acceptable sample size needed for chart
review
Performed extensive chart review of all fall patients
DMAIC
How are we doing?
IPF/1000 BCD (3)*
In-patient falls (IPF)
4
760
740
720
700
680
660
640
620
600
580
560
540
3.5
3
2.5
In-patient falls
(IPF)
2
IPF/1000 BCD (3)*
1.5
1
0.5
0
2004
2005
2006
2007
2004
2008
2005
2006
2007
2008
2004
2005
2006
2007
2008
In-patient
falls (IPF)
737
617
673
726
717
IPF/1000
BCD (3)*
3.2
3.4
2.6
3.0
2.9
DMAIC
How it comes together ...
At the end of measure, the team had/knew:
• A list of potential variables
• The critical input, process and output measures
• The measurement system was accurate
• What patterns were exhibited in the data
• What the current process capability was
DMAIC
Analyze
Analyze Deliverables
A.
B.
Identify variation sources
Establish performance objectives
DMAIC
Cause and Effect Diagram
Process
Assess. Tool
Misinterpretation of
Assessment tool
Morse scale:
Bed rest =0
Staff unaware
X Lack of hourly
X
Of change in status
rounding
Family failure to C
Notify staff on
Untimely D/C
C
departure
Planning
X
C
No standardized X
process
C
Only 1 tool used in
Assessing pt risk
Assessment criteria
X
Communication
Decrease in non-slip
footwear given to C
Pts.
Checking for recalled C
items
Lack of comm
X Infrequent obs.
On transfers
Of pat.
X No daily review
For mod risk pts.
X
X
X
Failure to comm. Pt.
Status accurately (Family)
No communication to pt
About risk
No
communication
to family
X
About risk
X Lack of comm. btwn
staff
Patient Falls
Unaware of
Morse scale
Category rules
Lack of chart reviews
Failure to notify staff of
Departure from pt.
room
C
X
Residents unplugging C
Bed alarms
Placement of teleC
Monitors (block call bells)
C
Poor lighting
C
Tripping hazards
Inside pt room
Physicians
X
X Misplacement of
Bed pad
Mislabeled call
lights
X Clutter in rooms
X
Location in the room
Environment/Other
Lack of knowledge
Of appropriate equip C
usage
Review annual
competency
X
Tracking
competency
X
N : Noise
X:X
= something that adds variability to our Y yet can’t be helped
= a factor that drives our Y
X
Lack of safety awareness
X No knowledge of falls
Prevention program
Education
C : Constant = something that doesn’t change
C
DMAIC
Impact/Effort Grid
1.
Nurses’
interpretation of
the Morse Scale
2.
Fall score day of fall
3.
Medication within 6
hours of fall
4.
Patient age
5.
Location in room
6.
Mental status the
day of the fall
7.
Orientation on the
day of the fall
High/Low
1
High/High
2
Low/Low
4
3
Low/High
7
6
Impact
Effort
5
What did we learn from Analyze?
Information collected from chart reviews
• Inconsistencies in documentation
• Fall score lowered day before fall: 38%
• Neuro section of the nursing flow sheet discrepancies: 18%
• Patient’s orientation on the day of fall was not reflected in the scoring
of mental status on the Morse scale
• No existing documentation on effectiveness of interventions
• Confusion with the use and interpretation of the Morse Scale as an
assessment tool
• Inconsistent application of the intervention protocol resulted in
patients falling multiple times during their hospital stay
• Lack of documentation supporting changes made to the fall score
*Based on 154 charts reviewed
What did we learn from Analyze?
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Change of shift
88% did not fall during shift change
Location of fall
82% fell near the bed
Day of the week
No statistical significance
Time of the day
No statistical significance
LOS
No statistical significance
Based on 154 charts reviewed
Survey results
•77% of Nurses surveyed felt the Morse scale is not
an effective assessment tool (Sample: 100)
•42% of staff surveyed felt that *standard
interventions are not effective (Sample:100)
•36% of staff surveyed felt bed alarms are effective,
but the response time is an issue (Sample:100)
•60% are not aware of the amount of falls occurring
on their units (Sample:124)
•74% are aware of the falls safe program
(Sample:124)
*two side rails, magenta (safety) bands
DMAIC
How it comes together ...
By the end of the Analyze Phase, the team was able to show
which causes they would focus on in the Improvement Phase by
describing:
• Which potential causes they identified
• Which causes they decided to investigate and why
• What data they collected to verify those causes
• How the data was interpreted
DMAIC
Improve
Improve Deliverables
A. Screen Potential Causes
*List of Vital Few “X’s”
B. Discover Variable Relationships
*Propose Solutions
C. Establish Operating Tolerances
*Pilot Solution
DMAIC
Root Cause Analysis
Factor
Root Cause
Proposed Solutions
No standard definitions for falls
Individual processes
Standardize falls definitions in
alignment with NDNQI
Falls assessment tool
(i.e. Morse Scale)
Confusion with interpretation and
use
Re-educate staff on the
appropriate use. Investigate
alternate user-friendly tools
No supporting data for changes
made to the Morse scale
Inconsistencies in documentation
Implement best practice from LTC
(post-fall assessment)
Missing information in Peminic
No fail safe hard stop enforcing
required documentation
Upgrades made to Peminic to
include hard stops to enforce
required documentation
Inconsistencies in the use of fall
interventions
No validation on effective
interventions
Pilot improvements on unit with
high risk patients and Implement
strategic improvement template
for consistency
DMAIC
Pre-pilot Activities
The team followed a
specific algorithm to
complete task in
preparation of the
pilot.
DMAIC
Findings from Observations
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No consistency in interventions used
Staff opinions varied on which interventions were in use
No standard process for rounding
Many employees were not aware of unit fall rates
Most employees had no knowledge of unit action plans
Nurses expressed difficulty interpreting Morse Scale
Patients identified at high risk were not easily found
when reviewing pts charts
Fall precautions were not often followed on all patients
identified at risk for falls
Staff could not easily identify patients at risk for falls
DMAIC
Standard Improvement Strategies for Pilot
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Educate staff on the process, importance of rounding, expectations
and accountability
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Educate nurses on the appropriate use of the Morse Scale
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Consistency in initiating the “4 P’s” during hourly patient rounds
(rounding with a purpose)
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Post unit results in appropriate (visible) area as a constant reminder to
staff: “how are we doing with patient falls” to increase staff awareness
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Consistency in the use of standard interventions (magenta bands, two
bed rails, personal items within reach, bed alarms (where applicable),
falling star, chair alarms (where applicable)
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Discuss patients at high risk during morning huddles to increase
awareness
* 4 P’s = Pain, Position, Potty (Toileting) and Personal Items
DMAIC
Pilot Plan
Purpose:
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Implement improvement strategies while monitoring performance and
effectiveness of process and interventions to reduce preventable falls
due to inconsistent practice
Where/Who:
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2 nursing units identified with a high volume of patient falls (4NMarlton, 4NE Memorial)
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4 Members of the fall prevention team would work with staff to
implement improvement strategies, making adjustments as needed
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Staff would be surveyed on the perception of the current practice
Timelines:
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3/15/10-5/17/10
Debrief Sessions:
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Bi-weekly starting: 3/31/10 (Wednesday’s)
Pilot Plan- continued
Procedures:
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New procedures documented in SOP format
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Other materials needed and instructions were developed
Staffing:
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Utilizing existing staffing
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Fall prevention core team would be available for consultation purposes
Stakeholders:
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Extensive information about pilot was communicated to all (appropriate) key
stakeholders.
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All involved in the pilot were updated and educated accordingly.
Measurements:
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See attached data collection plan to monitor key indicators.
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Methods/tools developed to document what works, what doesn’t and who
would respond to unanticipated problems.
DMAIC
Metrics Page for Discrete Data
Result!
4NE-Memorial
Project Y
Target
Pre-pilot
performance
(1st Quarter ’10)
Post –pilot
Performance
(July ‘10)
Post –pilot
Performance
(Aug ‘10)
# of all patient
falls
3.85- fall
rate
10 falls
3.66- fall rate
1 fall
1.03- fall rate
3 falls
TBD-fall rate
4N-Marlton
Project Y
Target
Pre-pilot
performance
(1st Quarter ’10)
Post –pilot
Performance
(July ‘10)
Post –pilot
Performance
(Aug ‘10)
# of all patient
falls
3.46- fall
rate
10 falls
4.11-fall rate
3 falls
4.57-fall rate
2 falls
2.88-fall rate
DMAIC
FMEA
Write factual
narrative
description
Lack of
education,
knowledge
deficit, lack of
experience
Schedule testing Process issue,
(if necessary)
order not
completed
apporpriately,
poor commun.
Hand off, SBAR
Potential Cause(s)/
Mechanism(s) of
Failure
Potential for
repeat fall,
inappropriate
follow-up,
potential to
influence
disclosure of
information
10 Distraction, ,
dup of
documentation
Undiagnosed,
increase in
severity of
injury, death
10 Nurse
intimidated by
physcian esp. at
night, no use of
SBAR during
communication
P
r
o
b
Current Design
Controls
3 Occurrence
report follow-up
D
e
t
2
R
P
N
Recommended
Action(s)
60 Post falls form
Responsibility &
Target Completion
Date
Team will
discuss with
Sponsors on:
July 27, 2010
for next steps
and further
recommended
actions
FMEA was completed and recommended actions
included:
2 APN /ANM
rounds, quality
director
meetings, occur.
Report follow-up
2
40 Units in the red
must participate
in a mini project
similar to falls
pilot
•Implementing rounding with a purpose
Team will
discuss with
Sponsors on:
July 27, 2010
for next steps
and further
recommended
actions
•Standardizing system for accountability and followthrough
Contact info. not
correct, lack of
knowledge,
intimidated by
family, middle of
the night
42
3 Lack of
7 Occur report,
2
•Utilizing
post falls assessment
form
knowledge, no
Manager follow-
DOH, or Joint
Commission
visit,
Dissatisfaction
(pt./family) RCA,
PCI, Loss of
confidence in
staff
training on
up with nurse
disclosure,
info.
•Discussing
falls
patients during interdisciplinary rounds
not captured on
admission
•Including Pharmacy in interdisciplinary rounds once a
week
Actions Taken
New RPN
S
e
v
•Documenting factual narrative description of the event
Pt. Injured?
(YES)
Call family
immediately
Potential Effect(s)
of Failure
New Det
Potential Failure
Mode(s)
New Occ
Item / Function
New Sev
Action Results
Improve
Fall Prevention
Prioritizing the Variables to achieve Six Sigma!
Rounding with a Purpose: Audit tool and SOP’s, Badge Buddies, 4P’s, PCT
rounding expectations (with and without clock). Falls will be standing item on
unit based council agenda.
Post Falls Assessment: Requesting all elements to be available in Peminic.
Model under development.
Interdisciplinary Rounds: Daily goal sheet and shift report, encouraged to
ask “what level of risk is patient?” instead of “Is patient at risk?”. Mandatory
standard use of falling star intervention.
Staff Awareness: Daily and weekly monitoring tool. Falls banner to increase
staff awareness.
Fall Education: Redesigned falls (online) education. Fall simulation developed
for clinical orientation. Education developed for clinical and non-clinical support
service departments
DMAIC
DMAIC
Next Steps for Control
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Inform organizational leaders of the changes made to
the process
Develop tools needed to sustain improvement
(Control plan, SOP’s, Virtual Tool Box, Informational
share point sites, etc.)
Communicate changes made to the process to key
stakeholders Virtua wide
Educate key stakeholders on the process Virtua wide
Roll out and implementation of improvement
strategies Virtua Wide
Questions?
Reducing variation to achieve 6 sigma one defect at a time!