August 22, 2017
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August 22, 2017
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August 18, 2017
Change Management Helps Reduce Falls
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Background and the start of a solution
Weston County Health Services successfully eliminated resident falls with major injury by using a change management methodology and a team-based approach.
Falls in nursing homes can often have serious consequences. One out of five falls causes a serious injury such as broken bones or a head injury, according to the American Journal of Public Health. Falls are also a leading cause of traumatic brain injuries in seniors.
“We want every resident at Weston County Health Services to receive the best possible care, and reducing the potential for major injuries through fall prevention is one area we knew we could improve,” said JoAnn Farnsworth, “so we rolled up our sleeves and got to work.”
In December of 2015, Weston had 9 falls with major injuries for that month alone. By the end of 2016, the facility did not have any falls with major injuries for numerous months in a row.
Track, change, test and verify
The Weston team’s first step was to educate nursing staff on fall prevention interventions. Educational handouts, brochures and posters focused on the results from pre- and post-intervention audits and served as a tutorial on best practices.
Next, the facility implemented changes in its processes that could reduce potential falls. The Weston team reported and tracked all falls. When a fall occurred, the team conducted post-fall huddles and immediately implemented interventions for rapid change. The team then reviewed the findings at weekly interdisciplinary meetings to see whether an individualized change produced a favorable outcome. Weston slowly saw results through changing, testing and verifying each individual outcome. Solutions were shared and applied to other residents when possible, and the team also sought help from family members to help determine the root causes of falls.
Weston implemented the following individualized interventions that produced results:
– Moved a resident’s bed to allow him/her to get out of bed on the opposite side
– Purchased a new chair for positioning and safe mobility without sliding off the chair
– Placed back-up brakes for residents who forgot to put on wheelchair brakes
– Created individualized toileting schedules
– Placed flat mats at bedsides
– Created a performance improvement project (PIP) on call light response times
– Created a quality assurance plan for call lights to be within reach at all times
Weston used the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report provided by Mountain-Pacific Quality Health as a tracking tool. Through a methodical process of trial and err, Weston successfully used change management to produce favorable outcomes to practically eliminate fall-related major injuries in its facility. Weston’s fall rate with major injuries is now well below state and national standards.
“Our entire staff is very proud of this accomplishment,” Farnsworth said. “When a resident gets hurt, we feel terrible. Our residents’ quality of life is very important to us. Weston Manor’s front-line staff has been the key to our success and we appreciate their hard work!”
About Mountain-Pacific—Mountain-Pacific is a 501(c)(3) nonprofit corporation and holds federal and state contracts that allow them to oversee the quality of care for Medicare and Medicaid members. Mountain-Pacific works within its region (Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands) to help improve the delivery of health care and the systems that provide it. Mountain-Pacific’s goal is to increase access to high-quality health care that is affordable, safe and of value to the patients they serve. www.mpqhf.org
Mountain-Pacific Quality Health
Mountain-Pacific Quality Health is a nonprofit corporation that partners within our communities to provide solutions for better health. We first opened our doors in Helena, Montana, in 1973; since then we have broadened our reach to include Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam, American Samoa and the Commonwealth of the Northern Mariana Islands.
Quality Innovation Network-Quality Improvement Organization
Part of what we do is under the direction of the Centers for Medicare & Medicaid Services (CMS). We are one of 14 Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs). We partner with health care providers, practitioners, stakeholders and patients on a variety of quality improvement initiatives to achieve better care, better population health and lower health care costs. These initiatives include:
- Preventing healthcare-associated infections in hospitals and nursing homes
- Preventing healthcare-acquired conditions related to long-term care in nursing homes
- Improving the coordination of care from one health care setting to another and reducing unnecessary hospital admissions and readmissions
- Improving cardiovascular health
- Improving the health and wellbeing of people with diabetes
- Helping providers with the use of electronic health records (EHRs) and health information technology (HIT)
- Helping providers with quality data reporting and related incentive programs
Mountain-Pacific provides Medicaid utilization review and management services for the Montana Department of Public Health and Human Services. We have been performing medical case review for specific Medicaid contracts since 1974. Through our review process, we strive to enable each Medicaid client to get his or her needs met in the most appropriate, cost-effective setting, using the most appropriate medical service, equipment and supplies.
Health Technology Services
Health Technology Services (HTS) is a department of Mountain-Pacific Quality Health. HTS is the federally designated Health Information Technology (HIT) Regional Extension Center (REC) for Montana and Wyoming. HTS offers technical assistance, guidance and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of electronic health records (EHRs).