Plan Do Study Act Worksheet
for GRU and MSK at Parkwood Hospital, London, Ontario
March 9, 2011 version-Fall Prevention Plan interventions for GRU and MSK patients(UPDATE)
Planning:
What change idea are you willing to test(between January 10-30, 2011)?
To develop and finalize an effective, consistent, interdisciplinary and time efficient strategy for fall prevention care planning for patients on GRU and MSK. The Care Plan interventions for our high fall risk population will incorporate and enhance existing fall prevention practices.
To take a team approach in fall prevention care plan
What do you expect (predict) will happen (by Jan 30, 2011)?
We will have developed a finalized care planning to prevent falls based on several revisions after receiving interdiscipliniary staff feedback.
How will you know your change is leading to an improvement (by Jan 30/11)
Interdisciplinary staff demonstrated interest in reviewing the Fall Prevention Care Plan drafts and provided useful critical feedback to improve the Fall Prevention Care Plan.
Who will be involved?
Members of the Falls Prevention Committee and frontline interdisciplinary staffto provide feedback on each newly revised draft.
When specifically do you plan to carry out the test?
Between January 10 – January 30, 2011
Where will it take place?
On GRU and MSK
How will it be done?
Staff meetings (if occur), multiple small group discussions on an ad hoc basis when clinical workload allows, one-on-one discussions, e-mail
DO
Describe what actually happened(as of January 30, 2011)
9 drafts of ‘Standards of Practice for Fall Prevention for all GRU and MSK patients’chart were reviewed with Fall Prevention Team members and interdisciplinary staff for feedback and revisions. This is an interdisciplinary plan of care to prevent falls for our high fall risk population.
- the title of the above chart was changed to ‘Universal Standards of Practice for Fall Prevention for all GRU and MSK patients’as the ‘high fall risk’ patient was a global issue on our Units. The interventions selected were for high risk fallers. This would be the care plan for all patients.
- for patients that need a more individualized plan on top of the ‘Universal Standards of Practice for Fall Prevention for all GRU and MSK patients’, we developed a chart the ‘Possible Fall Prevention strategies for GRU and MSK patients assessed to be an extremely high fall risk’ for the interdisciplinary team members to consider to create & initiate an Individualized Care Plan.
Study
What did you learn from this test? (UPDATE As of March 7, 2011)
Although it took a lot of time to obtain input repeatedly from interdisciplinary staff as new drafts were created, these discussions have engaged many interdisciplinary staff to validate current practices and to look at new ways we can try to prevent falls in our high fall risk population ( the majority of patients) using an interdisciplinary team approach.This time for staff input in the process was needed to shift culture and obtain buy-in from staff so that changes are more likely to be adopted and sustained
Act
Will you adopt, adapt or abandon the change? (UPDATE as of March 7, 2011)
1. The title ‘Possible Fall Prevention strategies for GRU and MSK patients assessed to be an extremely high
fall risk’ chart was changed to the ‘Individualized Care Plan for Fall Prevention for GRU and MSK patients
assessed to be an extremely high fall risk’ based on feedback from staff that former title wasn’t clear.
2. Sixteen interdisciplinary staff have received 30-45 minutes teaching about the ‘GRU and MSK Fall
Prevention and Management Program’ including the ‘GRU and MSK fall risk assessment and prevention
tool’ ( which includes the Morse Falls Scale), the ‘Universal Practice Standards for Fall Prevention for all
GRU and MSK patients’ and the ‘Individualized Care Plan for Fall Prevention for GRU and MSK patients
assessed to be an extremely high fall risk’. Teaching will continue until all interdisciplinary staff are
educated. 3. Implementation of above tools into admission processes will begin by mid- March, 2011
How does this connect with your next test of change?
Prevention of falls and injuries was first step. Management of a fall and the outcome of a fall is the next step - a ‘Post Fall’ Flowchart and ‘Head Injury Routine’ flowchart are the next step and in process of development
Submitted to Falls Community of Practice March 10, 2011