Originally posted November 15, 2018 by |Dr. Elizabeth Fiegel
The gap is in monitoring, measuring and adherence to evidence based standards of care. Human factors engineering strategies with MHDI create long term success. Our partners have seen a 50% reduction in falls with injury in 90 days by utilizing the RHD Model.
The fall with injury incidence in an older adult creates billions of dollars lost in avoidable healthcare expense and worse yet, reduces the lifespan of an older adult by one year. Despite the work performed in evidenced based bundles, standardized order sets, clinical education, and assistive clinical tools designed to reduce risk (beds, alarms, monitoring, mats, tech, medication management), the incidence of falls with injury has not been significantly reduced. By identifying high risk patients for fall INJURY, and planning care appropriately, ensuring implementation, then monitoring the effectiveness of that care helps to reduce variation.
Leadership accountability, alignment, transparency, and action integrated into the RHD Quality Design Model provides standard work and dramatic results in fall injury reduction. In addition, utilizing standard communication tools such as huddles, briefing, debriefing, SBAR and using standard checklist ensures appropriate alignment and standardization or High Reliability 24/7. It’s imperative that for every fall with injury, there is an immediate debriefing, and post fall huddle communication tool shared with the key stakeholders; lessons learned must be tracked, trended and Zero Harm adopted into the plans of action. Please ask your team members this very important question “What are you doing to keep your patients safe tonight”.
Front line leaders and staff members want to keep their patient’s safe 24/7, and require leadership to support and monitor adherence to the agreed upon standards of practice. Next week, let’s discuss how to equip our leadership with the tools to ensure they are successful in managing change to keep our patient’s safe, and are owners of this process.