VISN 8 Patient Safety Center of Inquiry: Journey for Change: Innovations to Reducing Fall Incidence and Injury Session

1. VISN 8 Patient Safety Center of Inquiry: Journey for Change:Innovations to Reducing Fall Incidence and InjurySession 7 Thursday, January 31st, 2013

2. Program Goal To provide VHA healthcare and quality teams with tools and strategies to reduce preventable falls incidence, injury from falls and outline key components of sustaining and spreading successfully.

3. Objectives • Inventory tests of change in fall and injury prevention interventions • Differentiate types of falls as a basis for analysis of program effectiveness • Integrate injury prevention into existing fall prevention programs • Summarize successes ready for adoption and spread

4. Looking Ahead Eight Sessions of Learning and Sharing • Oct 25th: State of Science of Falls and Injury Prevention • Nov 8th: Integrating Falls and Injury Assessment • Nov 29th: Interventions to Reduce Falls and Harm, Part 1 (Equipment and Technology) • Dec 20th: Injury Risk Assessment and Communication of Risk • Jan 3rd: Sustain and Spread Improvements in Reducing Falls and Injury from Falls • Jan 17th: Interventions to Reduce Falls and Harm, Part 2 (Intentional Rounding, Pre-shift Huddle, Post Fall Huddles) • Jan 31st: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation • Feb 7th: Summary of Your Accomplishments

5. Session 7: Use of VANOD, NDNQI and SPOT Databases for Fall Program Evaluation Learn new and expanded strategies to conduct your fall and fall-injury program evaluation: • Multiple data sources for program evaluation: • V.A. Nursing Outcomes Database: Featuring Mimi Haberfelde, RN-BC, MS • National Database for Nursing Quality Indicators: Pat Quigley • SPOT (fall and fall injury reporting database with NCPS): Julia Neily, RN, MS, MPH • Program evaluation, data available from each database and strategies to monitor your program.

6. Organizational Self Assessment – Section 1, Leadership, Part B. Data and Injury Program Evaluation B. Data and Injury Program Evaluation • Fall Rates by Type of Fall (Accidental, Anticipated Physiological, Unanticipated Physiological) • Fall-related Injury Rates by Severity of Injury • Fall injury rate reported per unit and hospital- wide by severity level and type of fall • Analysis of Repeat Fallers • Analysis by Age Groups (<55, 55-65, >65-75, >75) • Falls with injury trend data are compared with staffing • Amount of Annual Staff Education on Fall Prevention? • The entire fall prevention program is analyzed at least annually and evaluated for potential risk factors and opportunities for improvement • Trended injurious falls data are reported to the Board of Directors/Senior Leaders • Falls with injury prevalence (NQF) Quarterly, Unit and Hospital is reported to team or unit • Falls with injury prevalence (NQF) Quarterly, Unit and Hospital is reported to Extranet measures • Data analysis at Organizational and Unit Levels

7. VA Nursing Outcomes Database (VANOD)Getting to Falls Data March 2012 Mimi Haberfelde, RN-BC, MS Nursing Informatics Specialist

8. Goal and Vision of VANOD Goal: to create a national database of clinically relevant, nursing-sensitive quality indicators to identify trends and areas for improvement in order to: • Improve the quality and safety of healthcare for veterans • Support strategic decision-making through benchmarking • Support data driven decisions for clinical practice and staffing methodology • Evaluate relationships between nursing-sensitive indicators and patient and staff outcomes Vision: to be recognized as a valued, essential producer of reliable and usable information for both clinical and administrative decision making

9. VANOD Business Rules • No additional data collection burden to front line clinicians • Leverage existing data sources • Create new data sources when necessary • National roll-up of data for reporting • Provide facility tools to understand and validate data

10. VANOD - Post-Falls Note History • August 2007 - A National Collaborative Workgroup on Patient Falls developed desired patient falls data (ONS, PCS, NCPS, VISN 8 Patient Safety Center; GRECC, and field representatives) • Fall 2007 - A Field Workgroup represented 23 VA facilities developed the Post-Fall note • Winter 2007 - Post-Falls Note was pilot-tested by 21 of those sites • June 2008 – Post Fall Note posted on FORUM as an optional tool for facilities to import

11. Post-Falls Note History (cont) • April 2011 – NCPS approached VANOD re falls rate data • June 2011 – 40 – 50 facilities appeared to be using the Post-Falls Note • August 2011 – 10 facilities completed data validation

12. Data Captured from Post-Falls Note • Patient Fall Rate (rate of patient falls during hospitalization) • Repeat Falls Rate (rate of patients who fell more than once during hospitalization) • Falls with Injury Rate (rate of patients who fell with initial assessment of: Change in range of motion New deformity New injury New Laceration New Swelling

13. Data Validation Findings • Data capture requires use of Post-Falls Note – data matched if note was used • Data matched in 75% of falls in comparison to facility Patient Safety lists – discrepancies largely lack of consistency in template use) • Need for template modifications to enable of more accurate data capture (e.g. verification the patient fell; capture of additional falls on the same day, etc)

14. Expedited NSR Process • November 2011 – New Service Request for Post-Falls Note submitted for an expedited process • April 2012 – Post-Falls assigned to a developer • Sept 2012 – Usability conducted by Human Factors colleagues • Oct – Dec 2012- review by relevant committees • Anticipate patch release to pilot sites in Jan-Feb 2013 for functionality and data validation • National release pending successful pilot testing

15. Benefit of National Template • National Process: • Released to all facilities as a patch • Note titles and terms are standardized and locked down (means non-site configurable) • Pro: Standard data entry and data extraction • Ability to obtain national: Falls rate by ward days of care Falls with injury rate Repeat falls rate Facility falls information by nursing unit • VANOD and IPEC will partner to provide falls rates and falls with major injury

16. Established in 1998 by the American Nurses Association in response to ANA’s Safety and Quality Initiative. This program was based on the successful implementation of a series of pilot studies conducted by ANA in seven states.

17. Nurse Sensitive Measures • Nursing-sensitive measures reflect the structure, process and outcomes of nursing care. • Structure is indicated by the supply, skill level and education of nursing staff. • Process measures aspects of nursing care such as assessment, intervention, and RN job satisfaction. • Patient outcomes are those that improve if there is a greater quantity or quality of nursing care (e.g., pressure ulcers, falls, and IV infiltrations).

18. Current Indicators • Catheter-Associated Urinary Tract Infection Rate* • Central Line-Associated Blood Stream Infection Rate* • Fall/Injury Fall Rates** • Hospital*/Unit Acquired Pressure Ulcer Rates • Nursing Hours per Patient Day** • Nursing Staff Skill Mix** • Nurse Turnover Rate* • Pain Assessment/Intervention/Reassessment Cycles Completed • Peripheral IV Infiltration Rate • Physical Restraint Prevalence* • Physical/Sexual Assault/Injury Assault Rates • RN Education/Certification • RN Survey with • o Practice Environment Scale* • o Job Satisfaction Scales • Ventilator-Associated Pneumonia Rate* *NQF Measure ** ANA is the measure steward

19. Comparison Data • NDNQI Reports provide comparison data for all indicators based on unit classifications and facility characteristics. • Comparison data are owned by ANA and may not be published by NDNQI member hospitals.

20. Purposes The patient falls indicator are designed to: 1) Determine the rate at which patients have a fall 2) Determine the frequency with which patient falls result in injury 3) Explore the relationship between nursing assessments performed, interventions used, and falls

21. Core NDNQI Data for Falls and Fall-Related Injury Age Gender Fall Risk: (Identify the Scale Used) • Assessment prior to fall ; Scale score; • Time since last risk assessment; • At risk for Falls (y/n) Fall Prevention Protocol in Place Falls • Assisted Fall • Repeat Falls Injury Level Physical Restraint Prior Fall this Month

22. Rates Reported Three quarterly rates are reported: • Total Falls per 1,000 Patient Days • Injury Falls per 1,000 Patient Days • Unassisted Falls per 1,000 Patient Days Numerator = # of falls/injury falls per month times 1,000 Denominator = monthly patient days Quarterly rate = average of monthly rates

23. Repeat Falls More than one fall in a given month by the same patient after admission to this unit, may be classified as a repeat fall. Patients who fall elsewhere prior to admission to the unit are not classified as a repeat fall. Falls occurring on a previous admission to the same unit within the same month are considered repeat falls. During data entry, you are able to identify repeat falls when they occur within the calendar month and on the same unit.

24. Reports Provided • Unit Summary Analysis • Section / Type of Unit Analyses • Organization level • Analysis by Type of Hospital, Magnet Status, Teaching Facility Status, Ownership (Gov, non-Gov, For Profit, not-for-Profit)

25. Injury Level When the initial fall report is written by the nursing staff, the extent of injury may not yet be known. Hospitals have 24 hours to determine the injury level. None—patient had no injuries (no signs or symptoms) resulting from the fall; if an x-ray, CT scan or other post fall evaluation results in a finding of no injury Minor—resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion Moderate—resulted in suturing, application of steri-strips/skin glue, splinting, or muscle/joint strain Major—resulted in surgery, casting, traction, required consultation for neurological (basilar skull fracture, small subdural hematoma) or internal injury (rib fracture, small liver laceration) or patients with coagulopathy who receive blood products as a result of a fall Death—the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall)

26. NCPS Falls Workgroup Goals- Julia Neily • Goal #1:  Fall and Fall Related Injury Prevention • Goal #2: National fall and fall related major injury rates • Goal #3:Improve SPOT utility related to falls • Goal #4:VANOD post fall note collaboration

27. IPEC fall related definitions Acute, Long Term Care, Behavioral Health • Fall Loss of upright position that results in landing on the floor, ground, or an object or furniture, or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or stair; excluding falls resulting from violent blows or other purposeful actions. • Major Injury: Any fall that sustains a fracture and/or trauma requiring emergency treatment; head trauma which includes patient’s head striking a surface or object and may include or result in any of the following: subdural hematoma, concussion, TBI or behavioral changes. The major injury definition includes Death—the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall).

28. Program Evaluation Process • Process by which individuals work together to improve systems and processes with the intention to improve outcomes* *Committee on Assessing the System for Protecting Human Research Participants. Responsible Research: A Systems Approach to Protecting Research Participants. Washington, D.C.: The National Academies Press: 2002.

29. Framing the Question • Do you want to change a process, improve a practice, or test a product on your unit? (Program Evaluation/QI) • Do you want to test the strength of an association or the effectiveness of an intervention? (Research)

30. Intended Purpose • Improve care for a specific population • Limited application (a clinical unit or clinic) • Process of self-monitoring and self-assessment • Results are applied in an effort to improve a process or a practice • Trends are monitored using process improvement tools (run charts, standardized reports)

31. Program Evaluation Process 1. Problem: The problem should be of interest to the clinical staff, unit, and or hospital. It should specify the population and the variables that are being studied. e.g. Is there a better way to complete hand off communication? Could findings from the project be useful in clinical practice? How can this question best be studied to improve our patient outcomes and care processes? 2. Purpose: A quantitative study identifies the key study variables, their possible interrelationships and the nature of the population of interest. In qualitative studies, the statement of purpose indicates the nature of the inquire, the key concept, and the group, community, or setting under study 3. Research Question/hypothesis: No specific research hypothesis or criteria for including staff or patients.

32. Program Evaluation Process 4. Variable identification: Post Fall Huddle Effectiveness 5. Conceptual/theoretical framework: Planned change theory. Small tests of change. 6. Literature review: What knowledge exists on the study topic? The literature review can help the researcher plan study methods, instruments or tools to measure the study variables. 7. Research design: The overall plan for gathering data in a research study. It is concerned with the type of data that will be collected and the means used to obtain the data. How will the practice change implemented?

33. Program Evaluation Process 8. Population- sample- setting Sample: Not specific – rather focus on a process or practice Sampling: Convenience methods. 9. Instruments/ tools- Checklists, surveys and / or instruments that do not have established psychometric properties The type used is determined by the data collection method (s) selected. 10. Data Collection- The gathering of pieces of information or facts.What data will be collected? How will the data be collected, who will collect the data? Where will the data will be collected? When will the data be collected? The data may be collected on subjects by observing, testing, measuring, questioning, or recording or combination of methods. 11. Data analysis-Organize, reduce and give meaning to the pieces of information. Involves the translation from common language or general research language to the language of the statisticians. When the analysis is complete, the results of the process or practice change is evaluated. 12. Results and Findings: The interpretations of results only apply to that setting and sample.

34. Data Management is Important Data or pieces of information obtained in the course of research should be: • simple and understandable • concise and precise • compared (tables, benchmarks, targets) • the basis for developing evidence based practice • used from research to improve practice • involved in collecting, analyzing, and using • used to make decisions, improvements, and actions Benchmarking-A standard or reference against which something or some process can be measured or compared. It is used to compare performance of providers or systems with a standard.

35. Types of Data/Levels of Measurement • Qualitative • Opinions/perceptions • Themes • Quantitative • Attribute (categorical) • Nominal • Ordinal • Variable (continuous) • Interval • Ratio

36. Program Effectiveness: Fall Prevention • Organizational Level: Expert interdisciplinary all team, program evaluation, leadership, environmental safety, safe patient equipment, anti-tippers on wheelchairs • Unit Level: education, communication-handoff, universal and population-based fall-prevention approaches • Patient Level: exercise, medication modification, orthostasis management, assistive mobility aides

37. Program Effectiveness: Protection from Serious Injury • Organizational Level: available helmets, hip protectors, floor mats, height adjustable beds; elimination of sharp edges • Staff Level: education, adherence, communication-handoff includes risk for injury • Patient Level: adherence with hip protector use, helmet use, etc.

38. Evaluations Methods • Prevalence Studies • Formative and Summative Evaluation Methods • Type of Falls • Severity of Injury • How are you assessing for injury? Duration? Extent of Injury? • Repeat Falls • Survival Analysis • Annotated Run Charts

42. Annotated Run Chart

43. Next and Final Session Session 8 Celebrating Improvement Together Thursday, February 7, 2013 12N-1PM ET