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CPSI Share                                              
1/5/2016 5:00 PM

Safety is a priority for the Saskatoon Health Region.  The Canadian Falls Prevention Audit Month helped the Saskatoon Health Region (SHR) learn what quality improvement was needed for their fall reduction strategy. Throughout the Saskatoon Health Region safety measures are working well to prevent injuries from a fall, however there are gaps in screening and understanding risk factors, and how to incorporate those components into a safety plan for individual patient and residents.

Daphne Kemp, the Regional Falls Reduction and Injury Prevention Coordinator, wanted to demonstrate how standard work could enhance quality improvement and address those gaps. Daphne could make recommendations from a macro level as she knew what was happening from chart reviews, but needed that validity to support improvements and move things forward. She started looking for an audit tool that was best practice, aligned with their strategy, and could be spread across the entire health region. The Canadian Patient Safety Institute's Falls Prevention and Injury Reduction Audit tool was the perfect fit.  "We liked the questions, the tool and the information it would provide for us," says Daphne Kemp.

For the 2015 Canadian Falls Prevention Audit Month, the SHR chose to focus on long-term care (LTC). There are 30 long-term care homes with about 2,200 residents in the region. Daphne led the audit, with the help of a practicum student to do background leg work. Special Care Project coordinators in each of the LTC homes supported the gathering of data for their residents. The raw data was then faxed to Patient Safety Metrics with Daphne reviewing and doing follow-up.

In addition, Daphne chose to audit three areas in acute care and she personally collected data from the convalescent unit, the rehabilitation unit and the transitional care unit. The audit information garnered from those units will help to spread the falls prevention strategy to other areas across the region.

One acute-care unit was able to determine from the audit data, that they needed to improve communication. Gaps were identified in recognizing risk factors and communicating when a patient was at risk. The unit chose fall prevention as a Mistake Proofing Project, an approach identifying and preventing mistakes that improve safety and increases staff engagement. It includes setting and tracing both long and short-term goals.   Staff champions on the unit are now developing an improvement plan on how to better communicate the risk of falling to the entire healthcare team that may be spread regionally dependant on the outcome.

Provincially, Saskatoon Health Region takes a holistic approach to reduce the number of bedrails and restraint use in Long Term Care.  Getting buy-in that you don't have to use restraints as it can increase functional decline as well as physical and emotional harm by providing a balance of alternative safety measures is another area where they will use the data. The audit tool has a percentage of use of restraints embedded in it which was another draw for the tool.

The SHR recognizes the importance of being transparent.  Not only do senior leadership see the results, they are also printed out and sent to each of the LTC homes so the staff can see how they are doing and compare their data with others.  The audit results are put together in partnership with Strategic Health Information and Performance Support that are displayed with graphs put together from the raw data so that staff can recognize and visualize where changes need to be made.

"People need to see it, visualize it and find value in it – the more transparent you are, the more improvement you will see," says Daphne Kemp. "If staff doesn't see it, they are not engaged in it. To have improvement efforts need to be staff driven and is very powerful; that is my goal down the line."

Daphne says that you need to ensure that everyone is aware and knowledgeable about the audit tool, how to do it and to fill out the audit form in its entirety so that you don't have to guess what the auditor meant. The next time they will provide more clarity and do more education with the auditors on how to conduct the audit itself and what information they need to have.

"An audit is a big task that can be daunting and overwhelming," says Daphne Kemp. "It is not easy to start and like anything you do for the first time you will always have some glitches. It was a learning process and like any quality improvement initiative, there are going to be challenges and you have to work through them. I could have thrown in the towel, but I saw value in the audit.  The next time we audit, we will keep improving and our data will reflect that."