[00:00:00] I think our greatest success from a quality journey perspective has been the engagement of our entire staff. That is a process that we've worked on for the last three years to really focus on outcomes. At the end of the day, care takes place at the bedside 24 hours a day. It doesn't happen in the administrative offices.
[00:00:25] And for us to make that occur, we've focused on our frontline staff and for them understanding what safety and quality is all about, how they play a key role there. And we demonstrate the data, we give them the data, and then we, uh, celebrate with them on our successes. We do, uh, have a lot of nursing home patients here and that are on multiple medications, uh, that make, of course, make them more prone to fall
[00:00:59] My grandmother [00:01:00] was admitted to the hospital for a routine blood transfusion. We expected her to stay for a couple of days and then be able to go home, but unfortunately, she sustained a fall with injury, which ultimately led to her death less than 15 hours later
[00:01:21] We've done a lot of work here at this hospital to prevent that from ever happening to anyone else. It's a small town. You really get close to each other, so other staff members knew my grandmother on a first name basis, and her passing really empowered them to wanna make a change. It helped change the whole culture of the hospital because you could connect the personal story to it.
[00:01:45] Um, people really felt the drive to wanna do something different We've made a lot of changes at the organization and the way we address patients who are at risk for falls since we started this program. Originally, we started doing the [00:02:00] fall risk assessments every shift, so we really worked to make it easy for them.
[00:02:05] We put the list of the medications in that risk assessment that increased their falls so that they could see that information readily. We changed everything to yellow, so we did yellow falling stars on the doors, yellow skid-free socks. Um, we did yellow bands, yellow patient instructions. And then to make it easy for the staff to get it right every time, we created little Ziploc bags and we put all that information in there.
[00:02:28] We called it our fall packs. So any time they identified a patient at risk for falls, they could just go grab the bag out of the box, and they have everything right there. We do have someone in the room every hour until, I think, 10 o'clock in the evening, and after that, then they do every two hours. But we address their position.
[00:02:47] Do they need to go to the potty? Um, do they have all of their personal, um, possessions near so they don't have to get up out of the bed to reach? And then, uh, is their pain [00:03:00] controlled? We have formed a multidisciplinary fall team, and of course, Quality Director Sarah is on that committee, myself, the managers of ICU and Med Surg, and we involve the frontline staff for input from them.
[00:03:16] She had kind of a little spell yesterday during therapy, so, um- Once she's clear again in 24 hours, then they'll write down- Everybody's important. The guy that cleans the floors is, is important. Uh, the fact that he does a great job may keep somebody from getting a staph infection. And if we can do our share of work of letting those folks know how we feel and how important their job are, and when that's reflected in a positive manner, we'll get a better response from our physicians.
[00:03:49] Within 30 minutes of a fall at our organization, it's the expectation that s- that the staff do a post-fall huddle. Okay, we had a fall today. Can y'all tell me what [00:04:00] happened? The nursing supervisor and CNA involved with the care of that patient are all involved in the huddle. Then they go through all the information together with that team, review the medications that that patient was on.
[00:04:11] That gives us the ability to, one, learn right there after the event what we did well or what we could have done better. So can you tell me what we could have done different maybe to have prevented the fall? And it also gives us the ability to trend, so we ask questions like, was staffing a issue, and was there a certain medication so we can trend the, um- impact.
[00:04:31] Then we'll also discuss it with the person that fell. What can we do to, to be a better hospital? Patricia, would you please let the charge nurse know to initiate the post-fall huddle? Everything we focus on is about zero patient harm. So any time we have a variance from our quality measurements, we break that down.
[00:04:50] We focus on it, we address it, to make sure that we are truly driving care and safety to the bedside. Call, don't fall. So please stay [00:05:00] safe and let us know if you're trying to get out of bed. Our data really tells the story. So we really are focused on making sure that we collect data in a timely manner, get that back out to the caregivers as quickly as possible.
[00:05:13] Uh, that's what really demonstrates where our performance benchmarks are. Since my grandmother's accident in 2010, we've made a lot of changes here at Natchitoches Regional. We've, um, hardwired in a lot of, um, standardized processes. We use, um, risk assessments, injury assessments, um, handoffs, patient safety huddles.
[00:05:38] We've incorporated a lot of, um, best practices that we've learned, um, from other facilities, and we use those in our everyday activities so that we can prevent falls with injuries from ever happening to anyone else. Although this was a big loss for my family, it is a big turning point for our hospital and our culture [00:06:00] so that we can make these changes and help others so that they don't have to suffer the same loss that we did.
[00:06:07] As organizations, we don't work in silos, so how we get better is learn from others and then they learn from us. We have always been an organization that believes in sharing our successes and our pitfalls, and we will learn together, and others can give us advice and direction on how to improve.
