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LEADING BETTER VALUE CARE
Reducing harm fr from falls in in hospital
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NSW Falls Prevention Network Forum
Malcolm Green 31 May 2019
LEADING BETTER VALUE CARE Reducing harm fr from falls in in - - PowerPoint PPT Presentation
LEADING BETTER VALUE CARE Reducing harm fr from falls in in - - PowerPoint PPT Presentation
LEADING BETTER VALUE CARE Reducing harm fr from falls in in hospital NSW Falls Prevention Network Forum Malcolm Green 31 May 2019 1 CLINICAL EXCELLENCE COMMISSION FALLS COLLABORATIVE Keeping older people safe in our care Aim Reduce
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FALLS COLLABORATIVE
‘Keeping older people safe in our care’
Aim
Reduce falls and serious harm from falls by 5% within 12 months
Inclusions: Age ≥70 years Inpatients in a health service Partial or assisted fall Exclusions: Staff, visitors
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Theory of Knowledge
Appreciation for a System
Psychology
- f change
Unwarranted Variation
“Every System is perfectly designed to deliver the results that it gets.”
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FALLS COLLABORATIVE
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Final Bundle
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Thinking Doing & Learning
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Many PDSA Cycles…..
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Very Small Scale Tests Hunches, Theories, Ideas Changes That Result In Improvement Follow-up Tests Wide-scale Tests of Change Implementation of Change
PLAN DO STUDY ACT
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CONTINUOUS RUN CHART
PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5
IMPLEMENTATION
PDSA 1,1,3,5 PDSA 1,1,3,5 PDSA 1,1,3,5
Periodical sampling
need to understand why 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Week 13 Week 14 Week 15 Week 16 Week 17 Week 18 Week 19 Week 20 Week 21 Week 22 Week 23 Week 24 Week 25 Week 26 Week 27 Week 28 Week 29 Week 30 Week 31 Week 32 Week 33 Week 34 Week 35 November 2018 December 2018 January 2019 March 2019 May 2019 July 2019 March April May June July August September October Periodical sampling
Falls in Hospital Collaborative Percentage of patients who 'insert intervention here' each week
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SERIOUS HARM FROM FALLS
- 11/40 teams have not had a SAC 1 or 2 for > 390 days
( duration of the Collaborative)
- 26/40 teams have not had a SAC 1 or 2 for > 100 days
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LHD team activity
QUALITY IMPROVEMENT DATA SYSTEM
Monitor falls data Resources
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CEC Quality Tools Web Site www.cec.health.nsw.gov.au
http://www.cec.health.nsw.gov.au/quality-improvement/improvement-academy/quality-improvement-tools
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QI ACADEMY
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Plan
Do Study Act Using Rapid- Cycle Testing
Why, evaluate the impact
- f potential changes
- n a given aim?
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Your Aim & Measures
- AIM
– Improve the performance of a paper aeroplane to maximize the distance it flies and the accuracy of the flight
- M e a s u r e s
– Distance in meters – Accuracy of the landing (total landing points)
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PDSA Cycle for Improvement
Act
- What changes
are to be made in next cycle? Abandon Adapt Adopt
Plan
- Assign
Roles
- Design/change
the plane
Study
- Results of the
flight
Do
- Fly the plane
- Record the distance
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PDSA Cycle for Im Improvement
Rules
- Only one design change per PDSA cycle
- Each team designs and commits to flying
- nly one plane
- All planes must have wings and be able to
fly
- Each design is flown by each of the three
pilots
- In order to fly you must get clearance from
the air traffic controller
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PDSA Cycle for Im Improvement
- Assign the following roles
- Team Lead
- Pilots x 3
- Data collection/scribe
- Design Team
- Decide on a Name for your TEAM
- Design and build a paper airplane for distance
Flight One Collect Your Baseline DATA
- Pilot 1, 2 and 3 will fly the plane and record the data;
Repeat
- Rapid Cycle: More cycles = more data = more chances to improve
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What is your theory ry?
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# Plan Do Study Act # What questions? Theories? Prediction What do you see? How Long? How did what you see match prediction? What now? Adopt, adapt, abandon? 1 2 3 4 5 6 7 8 9 10
25 20 15 10 5 1 2 3 4 5 6 7 8 9 10
PDSA Test Cycle Distance (M)
Data Collection on a Run Chart
PDSA Tracker
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# Plan Do Study Act # What questions? Theories? Prediction What do you see? How Long? How did what you see match prediction? What now? Adopt, adapt, abandon? 1 2 3 4 5 6 7 8 9 10
25 20 15 10 5 1 2 3 4 5 6 7 8 9 10
PDSA Test Cycle Distance (M)
Data Collection on a Run Chart
PDSA Tracker
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Let’s Play!
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