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 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

Appreciation for a System “Every System is perfectly designed to deliver the results that it gets.” Psychology of change Theory of Knowledge Unwarranted Variation

FALLS COLLABORATIVE

Final Bundle 7

Thinking Doing & Learning

PLAN DO STUDY ACT Changes That Result In Many PDSA Cycles….. Improvement Implementation of Change Wide-scale Tests of Change Follow-up Tests Hunches, Theories, Ideas Very Small Scale Tests 10

100% 10% 20% 30% 40% 50% 60% 70% 80% 90% 0% Week 1 PDSA 1,1,3,5 Week 2 PDSA 1,1,3,5 March Week 3 PDSA 1,1,3,5 Week 4 PDSA 1,1,3,5 Week 5 CONTINUOUS RUN CHART Week 6 PDSA 1,1,3,5 Week 7 April Week 8 PDSA 1,1,3,5 Week 9 Week 10 PDSA 1,1,3,5 Week 11 PDSA 1,1,3,5 Percentage of patients who 'insert intervention here' each week May Week 12 Week 13 PDSA 1,1,3,5 Week 14 PDSA 1,1,3,5 Week 15 PDSA 1,1,3,5 June Week 16 Falls in Hospital Collaborative Week 17 Week 18 Week 19 PDSA 1,1,3,5 Week 20 July Week 21 PDSA 1,1,3,5 Week 22 Week 23 August Week 24 Week 25 IMPLEMENTATION Week 26 Week 27 September Week 28 PDSA 1,1,3,5 Week 29 PDSA 1,1,3,5 Week 30 PDSA 1,1,3,5 Week 31 Week 32 October Week 33 Week 34 Week 35 November 2018 Periodical sampling Periodical sampling December 2018 January 2019 need to understand why March 2019 May 2019 July 2019

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

QUALITY IMPROVEMENT DATA SYSTEM Monitor falls data Resources LHD team activity

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 14

QI ACADEMY

Using Rapid- Cycle Testing P lan D o S tudy A ct Why, evaluate the impact of potential changes on a given aim?

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)

PDSA Cycle for Improvement Act Plan • What changes • Assign Roles are to be made • Design/change in next cycle? the plane Abandon Adapt Adopt Study Do • Results of the • Fly the plane flight • Record the distance

PDSA Cycle for Im Improvement Rules • Only one design change per PDSA cycle • Each team designs and commits to flying only 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

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

What is your theory ry?

PDSA Tracker # Plan Do Study Act # What questions? What do you see? How How did what you see What now? Adopt, Prediction Theories? Long? match prediction? adapt, abandon? 1 2 3 4 5 6 7 8 9 10 25 Data Collection on a 20 Run Chart Distance (M) 15 10 5 1 2 3 4 5 6 7 8 9 10 PDSA Test Cycle

PDSA Tracker # Plan Do Study Act # What questions? What do you see? How How did what you see What now? Adopt, Prediction Theories? Long? match prediction? adapt, abandon? 1 2 3 4 5 6 7 8 9 10 25 Data Collection on a 20 Run Chart Distance (M) 15 10 5 1 2 3 4 5 6 7 8 9 10 PDSA Test Cycle

Let’s Play!

Discussion What did you learn about rapid-cycle change projects?