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Fall Prevention Utilizing Six Sigma Methodologies to Improve Patient Outcomes. Presented by : Virtua’s Fall Prevention Team. What is Six Sigma?… . Methodology for achieving goals and objectives Quantitative technique for problem solving Comprehensive improvement process.

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Fall Prevention

Utilizing Six Sigma Methodologies to

Improve Patient Outcomes

Presented by: Virtua’s Fall Prevention Team

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What is Six Sigma?…

  • Methodology for achieving goals and objectives

  • Quantitative technique for problem solving

  • Comprehensive improvement process

Tools For Driving Sustainable Change

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Define Deliverables

  • Develop Team Charter

  • Identify Project Critical to Quality (CTQ’s)

  • Define Process Map

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Team Charter

  • 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

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Opportunity Statement

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Voice of the Customer (VOC)!

VOC was captured to understand the problem

from the customers perspective

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High Level Process Map

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Stakeholder Analysis


Strongly Opposed




Strongly Supportive

Not all stakeholders are supportive of the initiative…now what?

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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.

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Measure Deliverables

  • Define performance metrics

  • Determine customer specifications and defects

  • Identify potential variables

  • Develop data collection plan

  • Establish process capability

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What is the right “Y” to measure?


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

# of inpatient falls

Target: < or equal to 3/1000 pt days

CTQ: 100% accuracy in falls assessment on admission

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Acute Care

Detailed Process Map

Patient falls during hospital stay

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Cause and Effect Diagram

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Data Collection

  • 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

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How are we doing?

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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

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Analyze Deliverables

  • Identify variation sources

  • Establish performance objectives

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Cause and Effect Diagram

C : Constant = something that doesn’t change

N : Noise = something that adds variability to our Y yet can’t be helped

X : X = a factor that drives our Y

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Impact/Effort Grid

  • Nurses’ interpretation of the Morse Scale

  • Fall score day of fall

  • Medication within 6 hours of fall

  • Patient age

  • Location in room

  • Mental status the day of the fall

  • Orientation on the day of the fall














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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

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What did we learn from Analyze?

  • 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

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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

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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

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Improve Deliverables

A. Screen Potential Causes

*List of Vital Few “X’s”

B. Discover Variable Relationships

*Propose Solutions

C. Establish Operating Tolerances

*Pilot Solution

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Root Cause Analysis

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Pre-pilot Activities

The team followed a specific algorithm to complete task in preparation of the pilot.

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Findings from Observations

  • 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

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Standard Improvement Strategies for Pilot

  • Educate staff on the process, importance of rounding, expectations and accountability

  • Educate nurses on the appropriate use of the Morse Scale

  • Consistency in initiating the “4 P’s” during hourly patient rounds (rounding with a purpose)

  • Post unit results in appropriate (visible) area as a constant reminder to staff: “how are we doing with patient falls” to increase staff awareness

  • 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)

  • Discuss patients at high risk during morning huddles to increase awareness

* 4 P’s = Pain, Position, Potty (Toileting) and Personal Items

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Pilot Plan


  • Implement improvement strategies while monitoring performance and effectiveness of process and interventions to reduce preventable falls due to inconsistent practice


  • 2 nursing units identified with a high volume of patient falls (4N- Marlton, 4NE Memorial)

  • 4 Members of the fall prevention team would work with staff to implement improvement strategies, making adjustments as needed

  • Staff would be surveyed on the perception of the current practice


  • 3/15/10-5/17/10

    Debrief Sessions:

  • Bi-weekly starting: 3/31/10 (Wednesday’s)

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Pilot Plan- continued


  • New procedures documented in SOP format

  • Other materials needed and instructions were developed


  • Utilizing existing staffing

  • Fall prevention core team would be available for consultation purposes


  • Extensive information about pilot was communicated to all (appropriate) key stakeholders.

  • All involved in the pilot were updated and educated accordingly.


  • See attached data collection plan to monitor key indicators.

  • Methods/tools developed to document what works, what doesn’t and who

    would respond to unanticipated problems.

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Metrics Page for Discrete Data




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FMEA was completed and recommended actions included:

  • Implementing rounding with a purpose

  • Standardizing system for accountability and follow-through

  • Documenting factual narrative description of the event

  • Utilizing post falls assessment form

  • Discussing falls patients during interdisciplinary rounds

  • Including Pharmacy in interdisciplinary rounds once a week

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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


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Next Steps for Control

  • 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

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Reducing variation to achieve 6 sigma one defect at a time!