Falls Prevention & Excellence
using quality data & communication
to reduce falls
May 2017
Kelley Lennon
Falls Prevention Program in HNE
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Background to program
Aim & method of program
Tools used to support program
Results
Background - 2014
• Approximately 350 falls per month occurred in 2014
across Hunter New England Local Health District.
• A significant number of falls involved injury with the
number of SAC 2 incidents consistently above
benchmark standards.
• Introduction of HNELHD patient falls monthly report
to assist in the identification of strategies for
improvement
• A falls reduction pilot project was developed in
response to this information
Patient Falls Report
• Developed to provide a global view of the patient fall
situation across HNE (commenced Jan 2015)
• Initially provided the following statistics:
– Number and type of fall (injury/ nil injury)
– Age, location, time and activity undertaken at time of
fall
– Units with high number of falls
• Refined to provide detail around actions to prevent falls,
particularly around corrective actions
Falls Reduction Pilot project
Aim:
 To reduce falls across HNELHD by 20% in a 12 month period.
Method:
 Pilot project conducted from 1st Sept 2015 – 30th Nov 2015
 Targeted units within 5 facilities across HNELHD – Armidale, Belmont,
John Hunter, Maitland and Moree which were identified in the HNE Patient
Falls report as recording higher than average number of falls
 Internal Excellence Coach Model
 Introduction of new or modified tools
 Strengthened accountability within local facilities
Tools to support program
**rationale for revised documentation was to reduce the volume of documentation,
by removing duplication & encourage specific clinical documentation through critical
thinking
Embedding existing tools:
• Risk assessment identification and care
planning – Adult Inpatient risk Assessment
Form
• Hourly rounding with patients – modified for
pilot
• Bedside Clinical Handover
• Patient care Boards
• HAIDET / ISBAR
Introduced tools:
• Safety Huddles
– A brief team meeting to identify patient risk
• Common cause/special cause tool (CCA)
– To record fall details and identify patterns
• Lean 5 Whys
– Question asking technique used to unravel the root
cause of falls
Huddle for Safety
• Improves communication of & focus on safety
issues for oncoming shift
• Consistent communication of patient risk
• Shares individualised risk reduction strategies
with whole team
• Stand up, preferably around EPJB
• 5-10 minutes prior to or after bedside
handover
Huddle Framework
Criteria
A
C
T
Assessment Issues:
• High Falls Risk
• Pressure Injury Risk
• Clinical Risk
Cognitive Issues:
• Confusion/ delirium
• Anxiety
• Impulsiveness
Treatment/Care Tactics:
• 2nd Hourly Toileting
• Assist mobility
• Falls Mat
• Nurse special
Pt Names/Bed Number
Huddles
Common Cause Analysis Tool
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Need to customise for each department
Completed by T/L at time of fall
Can be used to assist reporting incident details
Visual indication of commonality/variations and
opportunities for improvement
• Used at Huddle to connect staff to causation
behaviours
• Creates focus for Leader Rounding with staff &
patients
Common Cause Analysis Tool
The Importance of asking Why?
Interpretation of data
Actions
The 5 Why’s
• 5 Whys is an interactive question-asking technique
used to explore the cause-and-effect relationships
underlying a particular problem.
• The primary goal of the technique is to determine the
root cause of a defect or problem by repeating the
question "Why?" Each question forms the basis of
the next question.
• The "5" in the name derives from an empirical
observation on the number of iterations typically
required to resolve the problem.
Results of the pilot
Overall the results for patient falls has been positive with:
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An overall reduction in patient falls by 23.3% from
January 2015.
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100% reduction in SAC 1 incidents and 19.2% reduction
in SAC 2 incidents
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Reduction of 1.1 falls per 1,000 occupied bed days
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29% reduction of patient falls in pilot units
The falls numbers collected during the pilot period were compared
to the previous 12 month average for each chosen unit. All
targeted units showed a reduction in their falls numbers during
this period.
The average falls reduction percentage for all areas are:
District Results
Falls reduction Strategy/Program in HNELHD
Leadership
• Nursing & Midwifery Services to
develop resources and provide
support to health services
• 4 days workshops for Internal
coaches to develop skills which will
support the implementation of the
falls program
• Internal Coaches at the local level to
provide education and coaching to
frontline staff
• Building internal capacity,
identifying champions and local
education team
Coaching
• Executive Director, clinical services
nursing and midwifery, executive
sponsor
• GMs to provide sponsorship at a
service level
• DON to led program at local level
• NUMS to provide leadership and
accountability for frontline staff
• Educators to support staff to
understand strategies
• Allied Health to support staff and
consumers in Falls prevention
strategies
• Patient safety officer to support data
collection
• Falls Prevention Governance
committee provides direction
to the program in:
• implementing strategies
• identify gaps and actions
• review falls data
• validate outcomes
Governance