[00:00:00] I think our greatestsuccess from a quality journey perspective has been the engagement of ourentire staff. That is a process that we've worked on for the last three yearsto really focus on outcomes. At the end of the day, care takes place at thebedside 24 hours a day. It doesn't happen in the administrative offices.
[00:00:25] And for us to makethat occur, we've focused on our frontline staff and for them understandingwhat safety and quality is all about, how they play a key role there. And wedemonstrate the data, we give them the data, and then we, uh, celebrate withthem on our successes. We do, uh, have a lot of nursing home patients here andthat are on multiple medications, uh, that make, of course, make them moreprone to fall
[00:00:59] My grandmother [00:01:00] was admitted to the hospital for a routineblood transfusion. We expected her to stay for a couple of days and then beable to go home, but unfortunately, she sustained a fall with injury, whichultimately led to her death less than 15 hours later
[00:01:21] We've done a lot ofwork 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 membersknew my grandmother on a first name basis, and her passing really empowered themto wanna make a change. It helped change the whole culture of the hospitalbecause you could connect the personal story to it.
[00:01:45] Um, people reallyfelt the drive to wanna do something different We've made a lot of changes atthe organization and the way we address patients who are at risk for fallssince we started this program. Originally, we started doing the [00:02:00] fall risk assessments every shift, so wereally worked to make it easy for them.
[00:02:05] We put the list ofthe medications in that risk assessment that increased their falls so that theycould see that information readily. We changed everything to yellow, so we didyellow falling stars on the doors, yellow skid-free socks. Um, we did yellowbands, yellow patient instructions. And then to make it easy for the staff toget it right every time, we created little Ziploc bags and we put all thatinformation in there.
[00:02:28] We called it ourfall packs. So any time they identified a patient at risk for falls, they couldjust go grab the bag out of the box, and they have everything right there. Wedo 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 goto the potty? Um, do they have all of their personal, um, possessions near sothey 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 amultidisciplinary fall team, and of course, Quality Director Sarah is on thatcommittee, myself, the managers of ICU and Med Surg, and we involve thefrontline staff for input from them.
[00:03:16] She had kind of alittle spell yesterday during therapy, so, um- Once she's clear again in 24hours, then they'll write down- Everybody's important. The guy that cleans thefloors is, is important. Uh, the fact that he does a great job may keepsomebody from getting a staph infection. And if we can do our share of work ofletting those folks know how we feel and how important their job are, and whenthat's reflected in a positive manner, we'll get a better response from ourphysicians.
[00:03:49] Within 30 minutes ofa fall at our organization, it's the expectation that s- that the staff do apost-fall huddle. Okay, we had a fall today. Can y'all tell me what [00:04:00] happened? The nursing supervisor and CNAinvolved with the care of that patient are all involved in the huddle. Thenthey go through all the information together with that team, review themedications that that patient was on.
[00:04:11] That gives us theability to, one, learn right there after the event what we did well or what wecould have done better. So can you tell me what we could have done differentmaybe to have prevented the fall? And it also gives us the ability to trend, sowe ask questions like, was staffing a issue, and was there a certain medicationso we can trend the, um- impact.
[00:04:31] Then we'll alsodiscuss it with the person that fell. What can we do to, to be a betterhospital? Patricia, would you please let the charge nurse know to initiate thepost-fall huddle? Everything we focus on is about zero patient harm. So anytime we have a variance from our quality measurements, we break that down.
[00:04:50] We focus on it, weaddress it, to make sure that we are truly driving care and safety to thebedside. 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 tellsthe story. So we really are focused on making sure that we collect data in atimely manner, get that back out to the caregivers as quickly as possible.
[00:05:13] Uh, that's whatreally demonstrates where our performance benchmarks are. Since mygrandmother's accident in 2010, we've made a lot of changes here atNatchitoches Regional. We've, um, hardwired in a lot of, um, standardizedprocesses. We use, um, risk assessments, injury assessments, um, handoffs,patient safety huddles.
[00:05:38] We've incorporated alot of, um, best practices that we've learned, um, from other facilities, andwe use those in our everyday activities so that we can prevent falls withinjuries from ever happening to anyone else. Although this was a big loss formy family, it is a big turning point for our hospital and our culture [00:06:00] so that we can make these changes and helpothers so that they don't have to suffer the same loss that we did.
[00:06:07] As organizations, wedon't work in silos, so how we get better is learn from others and then theylearn from us. We have always been an organization that believes in sharing oursuccesses and our pitfalls, and we will learn together, and others can give usadvice and direction on how to improve.
.png)
