Description of the Call: Objectives: •To review the results of the Canadian Falls Audit Month 2015 •To discuss lessons learned from the audit month – strengths and areas for improvement •To gather ideas about how to improve the information submitted on falls prevention WATCH: http://bit.ly/1RkG84k

1. Canadian Falls Prevention Audit Month:
Results And Future Direction
May 20, 2015

2. Maryanne D’Arpino
Patient Safety Improvement Lead,
Canadian Patient Safety Institute
Today’s Facilitator

3. Welcome to our francophone
attendees
Bienvenue à nos participants
francophones
Hélène Riverin
Conseillère en sécurité et en amélioration
Safety Improvement Advisor

4. Pour nos participants francophones..
Pour accéder aux diapositives
français:
-Cliquez sur ​​l'onglet "FRENCH"
OU
-Envoyer un courriel à
helene.riverin@csssvc.qc.ca
Suivre la boîte «Chat» pour les
commentaires du
conférencière traduit en
français

5. Outline
 Background
– Falls Prevention Quality Audit Tool
– Falls Prevention Quality Audit Month
 Audit Month Results
– Participation
– Aggregated results by audit tool “column”
– Calculated results
– Relationships between variables
 Discussion & Next steps

6. Where to find our webinars…
pagehttp://www.saferhealthcarenow.ca/EN/events/NationalCalls/2015We
binars/Pages/default.aspx

7. 7
Please complete our poll

8. Today’s Speakers
Susan McNeill
Program Manager
Registered Nurses
Association of Ontario
Rosalie Freund-Heritage
Education Coordinator
Injury Prevention Centre
School of Public Health
University of Alberta
8

9. Background QI Audit Tool
 Standardized method to measure strategy
 Focuses on standards in the Getting Started Kit
 Looks at both processes of a strategy and
outcomes
 Helps meet Accreditation Canada standards
– “The team implements and evaluates a falls
prevention strategy to minimize client injury from falls”
 Tool for home, acute and long term care

10. Background Quality Audit Month
 National movement to establish baseline on
quality of prevention and management
 April 2015 data collection
 Recommendation to choose between 10-20
charts
 Data entered in Patient Safety Metrics
 Caution: limitations with
generalizability of 1 month data

11. Audit Participation
Falls Prevention Results
Falls Management Results
Falls Scores

12. Audit “Participants”

13. Participants by Province/Territory
N = 152
N = 3499

14. Audit Participation
Falls Prevention Results
Falls Management Results
Falls Scores

16. A. Type of Falls Risk Assessment
performed on Admission
18%
13%
16%

18. B. Patient designated 'at risk' and
status communicated
51%
67%
73%
N = 3444

19. Percent of ‘at risk’ communicated
77%
84%
78%
N = 2541

20. Assessment for ‘at risk’ patients

22. C. Medication review completed?
30%
78%
58%
N = 3400

24. D. Patient has documented
Falls Prevention / Injury Reduction Plan
45%
67%
61%
N = 3446

25. ‘At Risk’ Patients with documented
Falls Prevention / Injury Reduction Plan
64%
79%
66%
N = 2668

27. E. Completed Falls Risk Assessment following a
significant change in Medical Status?
54%
66%
36%
N = 1013

29. F. Patient is restrained at any time
93%
86%
97%
N = 3453

31. G. How many times did the Patient Fall?
90%
70%
66%

32. Frequency of falls among those who fell…
69%
62%
85%

33. Audit Participation
Falls Prevention Results
Falls Management Results
Falls Scores

34. Sector Number Percent by Sector
Acute Care 165 4.8%
Long Term Care 469 13.6%
Home Care 66 1.9%
Total 700 20.3%
Patients / Residents / Clients who fell

36. H. Was patient assessed for harm on
discovery of fall?
98% 97%
84%
N = 685

38. I. Harm from fall?
63%
57%
60%
N = 680

40. J. Completed fall risk assessment
following fall?
43%
29%
52%
N = 681

42. K. Monitored for 24-48 hrs after fall?
75%
83%
34%
N = 678

44. L. Falls Prevention / Injury Reduction Plan
reviewed/revised after fall?
53%
57%
39%
N = 688

45. Audit Participation
Falls Prevention Results
Falls Management Results
Falls Scores

46. You get 1 point for meeting the criteria for each Falls Prevention element:
• (A) Type of Falls Risk Assessment performed on Admission = Screen OR Full
• (B) Was patient designated "at risk" for Fall? = Yes OR No Risk
• (C) Medication review completed = Yes
• (D) Patient has documented Falls Prevention / Injury Reduction Plan = Yes OR No Risk
• (E) Completed Falls Risk Assessment following a significant change in Medical Status? = Yes OR N/A
Falls Prevention Score

47. You get 1 point for meeting the criteria for each Falls Management element
• (H) Was patient assessed for harm on discovery of fall? = Yes
• (J) Completed Falls Risk Assessment following fall? = Yes OR Not able to perform
• (K) Appropriate monitoring in place for 24-48 hrs after fall? = Yes OR Not able to perform
• (L) Falls Prevention / Injury Reduction Plan Reviewed/Revised After fall? = Yes
Falls Management Score

48. Falls Prevention and Management
Scores
19%
51%
28%
38%
46%
12%
N = 1187 N = 278

49.  Access your data and reports at any time in Patient
Safety Metrics
– Fall Prevention Score (Falls-Acute/HC/LTC 18)
– Fall Management Score after Fall (Falls-Acute/HC/LTC 19)
– https://psmetrics.utoronto.ca/metrics/login.aspx
 Overall organization results
– ‘Report’ tab > ‘Falls Prevention’ sub-tab
 Individual unit results
– ‘Data’ tab > ‘Falls-Acute/LTC’ intervention > ‘Measurement
Worksheet’ table
Your Results and Scores

50.  Who
– All teams that have not achieved goal
 When
– Monthly submission
 How long
– Until you maintain goal for three
consecutive months
Continued data submission

51. These results are:
Shocking
Expected

53. Next Steps
53

54.  Audits are used to increase awareness of
the need to measure your falls prevention
processes consistently over time
 Measurement data will signal which falls
prevention processes require attention
 Measurement is the key to understanding
if the changes you implement are
improving your falls prevention processes
Using Your Data for Improvement
54

55. Supporting Quality Improvement
in Falls Prevention
55
Call for
Action
Falls
Quality
Audit
Month
National
Results
National
Call:
Beyond
the Audit

56.  Falls Prevention Getting Started Kits
http://www.saferhealthcarenow.ca/EN/Interventions/Falls/Documents/Falls%20Getting%20
Started%20Kit.pdf
 RNAO Falls Best Practice Guideline, Prevention of Falls
and Fall Injuries in the Older Adult
http://rnao.ca/bpg/guidelines
 Improvement Guide GSK
http://www.patientsafetyinstitute.ca/English/toolsResources/ImprovementFramework/D
ocuments/Improvement%20Frameworks%20GSK%20EN.PDF
Resources
56

57. Please complete our poll
57

58. We are here to help!
58
 For Audit forms and Data Questions
CPSI Central Measurement Team
metrics@saferhealthcarenow.ca
Virginia Flintoft - 416-946-8350
Alexandru Titeu - 416-946-3103
 For Falls Prevention Content (Falls Intervention Lead)
Registered Nurses Association of Ontario (RNAO)
smacneil@rnao.org
 CPSI Patient Safety Intervention Lead
Maryanne D’Arpino MDArpino@cpsi-icsp.ca