Appendix A: PDSA Cycle Template

Project : Complete Fall Assessement & Intervention tool Date: Nov 24th 2011

PDSA Cycle Reporting Form

  1. What are we trying to accomplish? To which goal/aim does this link?

Improve the percentage of patients with completed falls risk assessment on admission on specific medical and surgical units (6NW, 7W, 8W, 8NW). Those units have been chosen as they are less compliant with the completion of the fall assessment tool and have a higher fall rate.

  1. How will we know that a change is an improvement? What will our measurementstrategy be? How does this link to our overall measurement and performance monitoringstrategies?

Audits will be performed monthly and the number of completed falls risk assessment tool at admission and for patients at risk of falls will be recorded and compared with monthly data.

  1. What changes can we make that will result in an improvement? How does this PDSAlink to other PDSA’s that we have planned?

Increase education and awareness of the multidisciplinary team on the importance of a completed fall assessment tool to decrease and prevent falls within the hospital.

PLAN (Date of Plan:December 2011)

What is our hunch that we that would like to test out?
Include a risk screening tool in admission package and remind nurses during multidisciplinary / nursing rounds to fill fall risk assessment tool.
What do we expect to happen?
Improvement in the percentage of completed fall risk assessment on admission and completed fall risk assessment for patients at risk of falls.
How will we measure progress?
Compare numbers monthly
Is this a pragmatic, realistic, learning cycle? Anything else we need to do?
This is a short, simple intervention to apply.

DO (Date of Do:December 2011)

Carry out the plan and document the actions
Nurses were reminded during multidisciplinary rounds about the importance of filling the fall assessment tool at admission and for patients at risk of falls
Record the data
Audits

STUDY (Date of Study:December 2011)

Reflect on what happened
It seems that the increase awareness (rounds/reminders) were not helpful that increase the percentage of completed fall assessment tool.
What does the data suggest?
Need to implement more thorough plan – next PDSA cycle

ACT (Date of Act: January 2012)

What have we learnt from this test of change?
Education and reminders are key factors in the completion of fall assessment tool.
What will we do differently as a result? What next?
Thorough plan and further PDSA cycle