SK Falls - Learning Session 1B - Safer Healthcare Now!

Learning Session 1B
Thursday June 2, 2011
9:00 a.m. – 12:00 p.m.

Welcome Back!
Linda Restau and Laurie Weiman
Ministry of Health

Collaborative Planning & Support Team
Dr. Jenny Basran, Collaborative co-Chair and Clinical Leader
Head & Assistant Professor, Division of Geriatric Medicine
College of Medicine, University of Saskatchewan
Geriatrician, Saskatoon Health Region
Linda Restau, Collaborative co-Chair
Saskatchewan Ministry of Health
Laurie Weiman, Collaborative co-Chair
Saskatchewan Ministry of Health
Debra-Jane Wright, Health Quality Council
Bruce Harries, Collaborative Strategic Advisor, Improvement
Associates Ltd
4-Jun-12
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 3

Collaborative Planning & Support Team
Leanne Couves, Collaborative Director, Improvement
Associates Ltd.
Tanis Rollefstad, Safety and Improvement Advisor, Safer
Healthcare Now! Western Region
Angela Thiessen, Administrative & Technical Support, Safer
Healthcare Now! Western Region
Nadine Glenn, Safety and Improvement Advisor, Safer
Healthcare Now! Western Region
Melissa Pope, Event Coordinator
4-Jun-12
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 4

Collaborative Faculty
Jody Rice, BScPT, Senior Physiotherapist Cypress Health
Region
Dr. Jane Richardson, BSP, PhD, FCSHP, Coordinator,
Clinical Pharmacy Services, Saskatoon Health Region
Dale Ternes, RN, BScN, Care Team Manager, Home
Care Heartland Health Region
4-Jun-12
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 5

Collaborative Faculty
Shanthi Johnson, PhD, RD, FDC, FACSM Professor and
Associate Dean (Graduate Studies & Research) Faculty of
Kinesiology & Health Studies Research Faculty, Saskatchewan
Population Health & Evaluation Research Unit
Cara Christian, Home Health Aide Regina Qu’Appelle Health
Region
Anita Meszaros, Occupational Therapist Kelsey Trail Health
Region
Patti Leugner, Special-Care Aide Pioneer Lodge Five Hills
Health Region
4-Jun-12
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 6

Aim of the Falls Collaborative
• Aim – reduce falls and injury from falls
among long-term care residents and home
care clients by at least 20% by March 2012.
4-Jun-12 7

Objectives for Today’s Session
By the end of this sessions, participants will:
• Review charters from Learning Session 1-A
• Learn more about measurement for
improvement
• Plan first test cycle using change concepts
from LS1-A
• Understand how you will be supported and
activities planned before Learning Session 2

Some feedback from LS1-A Poll
• Useful:
– Ideas to reduce falls e.g. Vitamin D
– Model for Improvement
– Examples
– Discussions
• To Improve:
– From “shorten” to “need more time” – balance!
– Interaction
– More time to work in our teams
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 9

Today’s Agenda
Handout:
• Review Collaborative Charters
• Measurement for Improvement
• Reporting – SHN & Monthly Reports
• Break
• Change Concepts & Ideas for Improvement
• Model for Improvement (Part 2)
• Action Period Activities, Assignments & Support
• Summary
4-Jun-12 10

Review Technology
Tanis Rollefstad
Safety and Improvement Advisor,
Safer Healthcare Now!

Interacting in WebEx: Today’s Tools
A few things on WebEx have
Changed!
Be prepared to use:
- Pointer
- Raise hand
- CHAT
4-Jun-12 12

Who is Online from Long Term Care
Type Team Member Names Here Today:
Extendicare Preston (Saskatoon)
Extendicare Parkside (Regina Qu’Appelle)
Kelvindell Lodge (Kelsey Trail)
Last Mountain Pioneer Home (Saskatoon)
LutherCare Communities (Saskatoon)
Moose Mountain Lodge (Sun Country)
Oliver Lodge (Saskatoon)
Parkridge Centre (Saskatoon)
Pioneer Lodge (Five Hills)
Pleasant View Care Home/Wadena Integrated Facility (Saskatoon)
Prairie North Health Authority
Providence Place (Five Hills)
Quill Plains Centennial Lodge and Health Center (Saskatoon)
Regina Lutheran Home (Regina Qu’Appelle)
Ross Payant Nursing Home (Five Hills)
Saskatoon Health Region
Sherbrooke Community Centre (Saskatoon)
Stensrud Lodge (Saskatoon)
Sunrise Health Region
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 13

Who is Online from Home Care
Team Member Names Here Today:
Athabasca Health Authority
Cypress Health Region (Home care/EMS)
Cypress Health Region (Accreditation Team)
Five Hills Health Region-Home Care
Regina Qu`Appelle Health Region
Saskatoon Health Region - Home Care
Sun Country Health Region
Sunrise Health Region Home Care
Anyone Else?
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 14

Reflection from LS1-A
Use “Chat to All Participants”
What was an a-ha moment?
Or
One activity since LS1-A?

Review Collaborative Charters
Nadine Glenn
Safety and Improvement Advisor,
Safer Healthcare Now!

Some Key Points
Project Name:
Team Members:
Team Sponsor:
WHAT ARE WE TRYING TO ACCOMPLISH?
HOW WILL WE KNOW A CHANGE IS
AN IMPROVEMENT?
Purpose of Project
Scope & Boundaries
Improvement Objectives
Measures
•
•
•
•
•
•
Improvement Charter
• What are your goals for next 10 mths?
• Specific objectives?
• What resident or client population will
your team focus on?
• Do you have any constraints?
Current Performance
1.
2.
3.
4.
5.
6.
Goals
1.
2.
3.
4.
5.
6.
• How will your team measure progress
towards your aim? Objectives?
• What data do we have? What data will we
need?
Project Name:
HOW WILL WE MANAGE THE IMPROVEMENT PROJECT?
Author:
Date:
Principles for Working Together
Improvement Charter
• Who is on your team?
• What will they do?
• How will we work together?
• How often do we need to meet?
Roles & Responsibilities
Review Schedule
Key Dates
WHAT CHANGES CAN WE MAKE THAT WILL
RESULT IN IMPROVEMENT?
Change Concepts and Ideas to Test
• Which ideas from Jenny and Anita’s
presentation “Top 10” stood out for your
team?
• Where could your team start?
Improvement Associates Ltd.
Page 1
Improvement Associates Ltd.
Page 1

From your Charter
Use “Chat to All Participants”
What does your team want to
accomplish by March 2012?

Example of Aim and Scope
AIM
• To decrease falls by 20% or more by March 2012.
SCOPE
• FHHR Home Care, home services clients team 1 &
2.
BOUNDARIES :
• Exclude team 3 clients at this time until process
tested
-Pauline Osemlak and team
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 19

Example of an Improvement Charter
Cypress Health Region Long Term Care Falls
Prevention Team:
Purpose of Project
• To decrease the # of residents that fall in
Cypress Health Region Long Term Care
facilities by 30% by March 31, 2012.
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 20

Measurement for Improvement
Nadine Glenn and Anita Meszaros

Distinctions in Measurement

Levels of Measurement
Typically, you will conduct measurement at
different levels in your project:
1. Project level: How will we know the change is an
improvement?
2. PDSA-level measures: to help you answer the
questions (predictions) in each PDSA cycle you
undertake
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 23

Recommended Measures
• Fall Rate – Number of falls per 1,000 resident (client) days
• Percentage of Falls Causing Injury
• Percentage of residents for whom a falls risk assessment
completed on admission
• Percentage of residents for whom a fall risk assessment
completed following fall, significant change or after 6
months
• Percentage of residents (clients) identified as “at risk” for
whom falls prevention and/or interventions implemented
• Use of physical and/or chemical restraints
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 24

Availability of Data in MDS
Tracked via
Measure
MDS - LTC
Falls rate per 1,000 client/resident days No No
Percentage of falls causing injury No No
Percentage of clients/residents with
completed falls risk assessment on
admission
Percentage of clients/residents with
completed falls risk assessment following a
fall or significant change in medical status
Percentage of “at risk” clients/residents
with a documented falls prevention/injury
reduction plan
No
No
Tracked via
MDS-HC
Restraint use Yes* No
No
No
No
No
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 25

Data from MDS (LTC)
(HC)
• Percent of residents
with daily physical
restraints
• Percentage of
residents on 9 or
more medications
• Percentage of
residents who have
fallen in last 30 days
(new)
• # or percentage
with falls last 90
days (prevalence
of falls)
• # or percentage of
residents with
Danger of Fall
• Number of
medications
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 26

Measurement Definitions
• Give communicable meaning to a concept
• Define numerator and denominator in
clear terms
• Includes the procedure for gathering,
displaying and interpreting data
– Sampling plan, stratification, graphs
• Not right or wrong – only useful

Definition of a Fall
• A FALL is defined as:
“An event that results in a person coming to
rest inadvertently on the ground or floor
or other lower level, with or without
injury”.
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 28

Definitions for Key Measures
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 29

An example —Falls with Harm
(expressed as a percent)
Numerator: Number of falls where injuries were
sustained (Let’s say there were 5 falls with injuries)
Denominator: Total number of falls in the facility (during
the specified time period (Let’s say there were 20 falls this
month)
5/20 multiplied by 100 = 25%
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 30

Data Display
• Plot data over time
• Include annotations
• Agree on method of interpretation

Annotated Run Chart - Example
50
45
Falls. 1- Falls Rate per 1000 Patient Days 1 West 2010
40
Falls/ 1000 Resident Days
35
30
25
20
15
All staff taught how to use
Event Reporting System
10
5
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
Falls per 1000 pt. Days Falls with Harm (%)

Quantitative and Qualitative
• % of high risk residents
with appropriate falls
prevention and
interventions
• Staff description on how
well the new intervention
are working

Tips for Data Collection
Integrate into daily routine
Don’t wait for perfect electronic systems -
use manual data collection
Use qualitative data
Design and test data collection forms to
make it easy to collect
Continually improve your data collection
system
34

Checklist: Measurement for
Improvement
Chose 2-6 useful measures
Using small samples
Collected frequently
Plotted over time
Reviewed by those involved in improvement
Used for learning (not punitive)
35

Our Purpose
Reduce falls and injury from falls among
long-term care residents and home care
clients by at least 20% by March 2012.
“You can’t fatten a cow by weighing it”
- Ancient Proverb

Next Steps and Ongoing Support
• Be ready to collect, submit and use data
• Help each other on the Google Groups
discussion forum

Improvement Team Meetings

Assignment for Team Meetings
• Purpose: Develop initial plan for
measurement. What will you measure?
How will you get the data?
• Suggest designating a measurement person.
• Method: In your working group (lines
muted).
• Support: Send chat message with question
• Time: 15 minutes

How to Join Your Team’s Breakout Room
3. Click “Yes”
1. Highlight TEAM
NAME
2. Click “Start”
or “Join”
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 40

Questions?
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 41

Informal Poll: Use or
How many teams have:
• Submitted an Excel worksheet to Central
Measurement Team?
• Taken Patient Safety Metrics System
(PSMS) training for the online system?
• Submitted data to SHN using PSMS?
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 42

Reporting through
SHN! Patient Safety Metric System
Alexandru Titeau
Project Coordinator, Central Measurement Team
Safer Healthcare Now!

SHN Reporting System
• Transition from Excel Worksheets to online PS
Metrics system
• Training for Collaborative teams in July
• Access for data entry
• Opportunity to enter data
– Baseline data for comparison: last 3 months if
possible
– Report monthly to measure improvement

Break
Return Time: _________

Overview of Fall Prevention Strategies
and Change Package
Dr. Jenny Basran
Anita Meszaros
All Faculty Members

Some Questions from LS1-A Poll
• How do we access falls prevention
equipment - wireless motion monitors and
hip protectors?
• How do we get “buy in" from staff, family,
etc.?
• How can we accomplish our goals of 20%
by March 2012? How to have involvement
over the summer months?
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 47

New Questions?
What questions do you have
now about the changes
suggested?
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 48

Change Package for Long-Term Care
• Interdisciplinary falls team assess and
manage risk factors for falls
• Assessment on admission, after a fall and
when change in level of function
• Track falls in single falls diary
• Start Vitamin D 3 (800 - 1000 IU OD) on all
patients
• Medication review by pharmacist should be
part of all fall assessments
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 49

Change Package for Long-Term Care
• Inspect & repair assistive devices (OT)
• Look for reversible causes of cognitive
impairment, especially if acute onset
(delirium) – UTI, constipation, pain, etc
• Increase supervision on the most frail and
cognitively impaired patients
• Hip protectors and helmets
• Environmental Scan – as part of fall
prevention plan
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 50

Change Package for Home Care
• Very limited studies on home care patients
specifically
• Strategies and Actions for Independent
Living (SAIL) program – Vicky Scott, BC
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 51

AGS / BGS Fall Prevention Guidelines 2010
• F
Summary of the Updated
American Geriatric Society /
British Geriatric Society
Clinical Practice Guidelines
for the Prevention of Falls in
Older Persons – Journal of
the American Geriatrics
Society 2010
www.americangeriatrics.org
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 52

Change Package for Home Care
• Screen all patients for fall risk
• History, physical /cognitive / function exam
• Multifactorial / Multicomponent
Intervention to address identified risks
• Evaluate gait & balance
• Minimize medication (reduce / remove)
• Individually tailored exercise program
• Supplement Vitamin D (800-1000 IU OD)
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 53

Change Package for Home Care
• Treat vision impairment (including cataract)
• Manage postural hypotension
• Manage heart rate and rhythm
abnormalities
• Manage foot and footwear problems
• Modify the home environment
• Provide education & information
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 54

Model for Improvement (Part Two)
Leanne Couves, Collaborative Director
Improvement Associates Ltd

pointer
What ideas might your team start with?
Long Term Care Teams
Home Care Teams
• Interdisciplinary falls team assess and
manage risk factors for falls
• Strategies and Actions for Independent Living
(SAIL) program
• Assessment on admission, after a fall and • AGS / BGS Fall Prevention Guidelines 2010
when change in level of function
• Screen all patients for fall risk
• Track falls in single falls diary
• History, physical /cognitive / function exam
• Start Vitamin D 3 (800 - 1000 IU OD) on all • Multifactorial / Multicomponent Intervention
patients
to address identified risks
• Medication review by pharmacist should • Evaluate gait & balance
be part of all fall assessments
• Minimize medication (reduce / remove)
• Inspect & repair assistive devices (OT)
• Individually tailored exercise program
• Look for reversible causes of cognitive
• Supplement Vitamin D (800-1000 IU OD)
impairment, especially if acute onset
(delirium) – UTI, constipation, pain, etc
• Treat vision impairment (including cataract)
• Increase supervision on the most frail and
• Manage postural hypotension
cognitively impaired patients
• Manage heart rate and rhythm abnormalities
• Hip protectors and helmets
• Manage foot and footwear problems
• Environmental Scan
• Modify the home environment
• Provide education & information
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 56

Page 1
Model for Improvement
PLAN
Handout
PDSA Cycles
Project Name: Cycle #:
Objective of this Cycle:
What change are we testing? What is our prediction and theory? Details of the plan (who, what,
where, when and how).
Carry out the plan. Record data and observations.
DO
Complete analysis and synthesis. Do the results agree with the predictions? Under what
conditions could the results be different? Summarize new knowledge.
STUDY
What action are we going to take as a result of this cycle (Adopt, Adapt or Abandon)? Are we
ready to implement? What other processes or systems might be affected by this change?
ACT
What are we trying to accomplish?
How will we know that a change is an improvement?
Objective of Next Cycle
Improvement Associates Ltd.
What changes can we make that will result in improvement?
Act
Plan
Study
Do
Source: Associates in Process Improvement

Creating a New System
Spread
Hold the Gains
Improvement
(test, implement)

3 Principles for Testing a Change
• Test on a small scale
• Collect data over time
• Build knowledge sequentially and include a
wide range of conditions in the sequence of
tests

Principle 1:
Test On a Small Scale
CONSEQUENCE
OF FAILED TEST
DEGREE OF BELIEF IN SUCCESS
OF THE CHANGE
LOW
HIGH
MINOR
Medium-scale
tests
One cycle to
implementation
MAJOR
Very small-scale
tests
Small-to-medium
scale test

Designing a Small Scale Test
• Simulate the change
• Have an expert review the change
• Test the idea with volunteers
• Use 1:1:1 rule – one clinician in one
location with one client
• Use manual “pencil and paper” data
collection
• Conduct the test over a short time period–
what COULD we do by next Tuesday?

Principle 2:
Collect Data Over Time
Do you think this change is an improvement?
YES NO
9
Before & After Tests
8
7
8
63%
Improvement
6
Cycle Time
5
4
3
2
Make Change
3
1
0
Week 4 Week 11
Source: Moen et. al. Improving Quality Through Planned Experimentation

10
Case 1
8
6
Cycle Time
4
Make Change
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week

10
Case 2
8
6
Cycle Time
4
Make Change
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week

10
Case 3
8
6
Cycle Time
4
Make Change
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Weeek

Case 4
10
8
6
Cycle Time
4
Make Change
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week

Case 5
10
8
6
Cycle Time
4
Make Change
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week

10
Case 6
8
6
Cycle Time
4
Make Change
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Week

Annotated Run Chart - Example
50
45
Falls. 1- Falls Rate per 1000 Patient Days 1 West 2010
40
Falls/ 1000 Resident Days
35
30
25
20
15
All staff taught how to use
Event Reporting System
10
5
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total
Falls per 1000 pt. Days Falls with Harm (%)

Principle 3: Build Knowledge Sequentially and Include a
Wide Range of Conditions in the Sequence of Tests
PDSA #1.2: Expand to all clients on
Mrs. J floor
PDSA #1.4: Adjust when Vitamin D
administered, expand to all clients at
Lodge X.
PDSA #1.3: Adjust Vitamin D
ordering processes in pharmacy
PDSA #2.3: Update
falls diary format and
try on all clients for 2
weeks
PDSA #2.2: Try revised falls diary with
1 high risk client next week
PDSA #1.1: Use 1:1:1 rule (Mrs. J at
Lodge X on Tuesday)
Idea #1: Start vitamin D
PDSA #2.1: Design a “falls diary”
prototype and ask 3 front-line staff how
to improve it.
Idea #2: Track falls in a falls
diary

Develop, Test and Implement
High
Change Concepts
introduced.
Collaborative Teams
start at “Testing a
Change”
A successful change
Degree of belief
that the change
will result in
improvement
Moderate
Change still needs
further testing.
There is a risk of
implementing at this
stage.
Low
Unsuccessful
proposed change
Developing a
Change
Testing a Change
Cycle 1, 2, 3…
Implementing a
Change
Source: Langley, et al. The Improvement Guide

Your PDSA Cycle
Go back to the Changes
Suggested…Pick One!
How COULD you test it by
next Tuesday?
PDSA Cycles
Project Name: Cycle #:
Objective of this Cycle:
PLAN
What change are we testing? What is our prediction and theory? Details of the plan (who, what,
where, when and how).
Hard Goal - MUST complete
one full PDSA Cycle by next
Tuesday.
DO
Carry out the plan. Record data and observations.
Complete analysis and synthesis. Do the results agree with the predictions? Under what
conditions could the results be different? Summarize new knowledge.
Soft Goal – PDSA Cycle can
be of any scale and/or size
that can meet the Hard Goal.
STUDY
What action are we going to take as a result of this cycle (Adopt, Adapt or Abandon)? Are we
ready to implement? What other processes or systems might be affected by this change?
ACT
Objective of Next Cycle
Improvement Associates Ltd.
Page 1

Page 1
Assignment for Team Meetings
Purpose: Pick an idea to test.
Method:
Support:
Time:
Plan your first small-scale test (what,
who, when, where, why, how)
In your teams (lines muted)
Send chat message with question
15 minutes
PDSA Cycles
Project Name: Cycle #:
Objective of this Cycle:
Handout
What change are we testing? What is our prediction and theory? Details of the plan (who, what,
where, when and how).
DO
PLAN
Carry out the plan. Record data and observations.
Complete analysis and synthesis. Do the results agree with the predictions? Under what
conditions could the results be different? Summarize new knowledge.
ACT
STUDY
What action are we going to take as a result of this cycle (Adopt, Adapt or Abandon)? Are we
ready to implement? What other processes or systems might be affected by this change?
Objective of Next Cycle
Improvement Associates Ltd.

How to Join Your Team’s Breakout Room
3. Click “Yes”
1. Highlight TEAM
NAME
2. Click “Start”
or “Join”
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 74

Team Reports
Use “Chat to All Participants”
What change will you test by next Tuesday?
Provide details…what, who, when, where, how
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 75

Your Questions
Raise Your Hand
or
Use “Chat to All Participants”

Action Period Activities:
Assignments & Support Infrastructure
Leanne Couves
Collaborative Director
Improvement Associates Ltd

The Collaborative Approach
Action Period One
Action Period Two
Action Period Three
A
P
A
P
A
P
S
D
S
D
S
D
Planning &
Pre-work
a) Teams
b) Topic
Learning
Session
One
(A&B)
- MAY JUNE -
Learning
Session
Two
- OCT-
Learning
Session
Three
- FEB-
Distribute
Findings
-MAR-
-APRIL & MAY-
Support
Team Calls List Serve Document Sharing Monthly Reports
Assessments Site Visits Faculty Coaching
*Based on Institute for Healthcare Improvement Breakthrough Series Collaboratives
4-Jun-12
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 78

Getting Started
• Assignments
– What to do next two days
– What to do in the first week
– What to do within the first month
• Role of senior leadership
• Support

What to Do within Next Week
• Complete first PDSA Cycle and email to me
at lcouves@telus.net by Tuesday!
• Meet with your team
• Update Improvement Charter

What To Do Within the First Month
• Meet with your sponsor
• Communicate aim and plans
• Start collection of data - who?
• Conduct multiple test cycles

Issues to Anticipate
• Where’s my team?
• The black hole of data collection
• Scope creep
• Action without learning
82 April 2011

Some Keys to Success
• Start small
• Test changes from change package
• Ensure data collection part of a PDSA cycle
• Engage the “keeners”
• Spread the work
• Focus on learning
83 April 2011

The Role of Sponsors
• Take status quo off the table
• Make project visible to others
• Ensure success of Collaborative teams
• Remove barriers and obstacles
• Plan and manage spread

The Collaborative Approach
Action Period One
Action Period Two
Action Period Three
A
P
A
P
A
P
S
D
S
D
S
D
Planning &
Pre-work
a) Teams
b) Topic
Learning
Session
One
(A&B)
- MAY JUNE -
Learning
Session
Two
- OCT-
Learning
Session
Three
- FEB-
Distribute
Findings
-MAR-
-APRIL & MAY-
Support
Team Calls List Serve Document Sharing Monthly Reports
Assessments Site Visits Faculty Coaching
*Based on Institute for Healthcare Improvement Breakthrough Series Collaboratives
4-Jun-12
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 85

Collaborative Support – Community of
Practice (CoP)
Safer Healthcare
Now! Community
of Practice (CoP)
• Saskatchewanspecific
folders
(closed
community)
• Document
storage and
sharing
• Calendar of
Events with
WebEx Links
http://tools.patientsafetyinstitute.ca/Pages/welcome.aspx
86
4-Jun-12
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC

List Serve
• List Serve Discussions using Google Groups
– Team members automatically registered
– Right to your Email Inbox!
– All replies to go all members
– Etiquette
– Email Address
skfallscollaborative@googlegroups.com
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 87

Team Calls
• Balance of sharing and education
• Focused on key changes
• Generate new ideas
• Identify ways to overcome barriers
• Facilitated by Planning & Support Team
• Suggested that at least two team members
attend

Mark Your Calendars – Team Calls
• Thursday’s at 9:00 a.m. for 1 hour
– June 16: Learning from Changes Tried, Answers to
Questions re: Change Package
– June 30: Learning from Changes, Intro to
Measurement Tools, More on Collaborative
Supports, Managing over Summer
– July 21: More on Measurement and PSMS
– Aug 18, Sept 15, Oct 20 – topics TBD
• Links will be emailed to you and posted to the
CoP Calendar
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 89

Monthly Reports
• For teams to discuss and communicate
their progress, what has been learned and
what is planned next
• Provides Faculty and Planning team with an
understanding of progress towards the goal
of the Collaborative

Narrative + Data
Submit narrative report
to Nadine Glenn
nadine.glenn@hqca.ca
on 5 th of the month
(starting July 5).
More details to come…

Next Learning Session (Face-to-Face)
• Purpose:
– Share results and learning's
– Plan additional testing cycles
– Build implementation plans
• Date and Location:
– Monday (p.m.) and Tuesday (all day)
– October 24-25, 2011
– Saskatoon Inn (by the airport)

What to Do within Next Week
• Complete first PDSA Cycle and email to
lcouves@telus.net by Tuesday
• Meet with your team
• Update Improvement Charter

“Taking the Pulse” Poll
4-Jun-12 94
Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC

Immediate Next Steps
• By June 16 Team Call
– 1st PDSA Cycle - Test a change and email your
Cycle!
– Meet with full team
– Update Improvement Charter
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 95

Reminders
• All calls are recorded and links will be
available on Safer Healthcare Now!
Community of Practice and emailed to you
after this session
• Resources are available on the SHN
Website and Community of Practice - check
them out!
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 96

Questions?
Angela Thiessen, Project Coordinator
angela.thiessen@hqca.ca
403.521.7106
Nadine Glenn, Safety & Improvement Advisor
Nadine.glenn@hqca.ca
780.978.986
Leanne Couves, Collaborative Director
lcouves@telus.net
780.963.0844
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 97

Summary and Closing Comments
Dr. Jenny Basran
Linda Restau
Laurie Weiman

Thank You
Participating Teams
Faculty
Planning & Support Team
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 99

Collaborative Principles
• Everybody teaches, everybody learns
• Share generously (transparency)
• Steal shamelessly
• Acknowledge graciously
When we cooperate, everybody wins.
W. Edwards Deming
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 100

Funded and Supported By
4-Jun-12 Saskatchewan Falls Collaborative: Reducing Falls Reducing Harm in LTC and HC 101

Mark Your Calendars!
June 16 and 30 at 9:00 for Team Calls (1 hour)
October 24 and 25 for Learning Session 2
(1.5 days)