Ron Westlake, Nurse Manager and Elaine Detman, Clinical Coordinator at Allegheny Valley Hospital in Natrona Heights, PA share their thoughts and advice on preventing falls by taking action to improve compliance with best practices.

Q: You started using QualarisAudit to track compliance with Falls Prevention best practices in July 2014 on two units. Over the next six months you collected over 900 audits and achieved an upward trending compliance rate of 88%. Can you tell us how you approached this quality improvement journey at the beginning?

A: We decided to pilot the program on our Geriatric Psych units because those patients have particular issues with falls. Our Clinical Coordinators collected all of the data on those units and used it to provide immediate feedback in Daily Huddles and corrected any issues identified in real-time. In addition, our Falls Prevention Team met monthly to review the results of our data collection and due to the early success of our pilot project, determined in late 2014 to go housewide in all units with this project.

Q: How do you use QualarisAudit for this project? Can you be specific about what tools you use and when?

A: Since the Clinical Coordinators collect all of the data in the Audit Tool, they are able to use the knowledge they gain from that activity to provide input and offer feedback during the units' Daily Huddles and take immediate steps if anything needs to be corrected to protect our patients. The Falls Team uses the Dashboards and Reports to review our progress and determine where we need to focus our energy as a team to improve compliance with our best practices.

Q: Since expanding the Falls Prevention Project to all units in 2015, you have collected over 560 audits and have a compliance rate of 81% for the first quarter of the year; so your results continue to be impressive. What advice would you offer to your colleagues at other hospitals who are looking for ways to leverage the data they are gathering to take action toward improvement?

A: First, we would recommend that they look carefully at the questions on their audit to make certain the questions are relevant to the patient population they are serving and will have real impact on their falls outcomes. Also look for things that contribute to falls which are NOT reflected on your audit checklist and consider whether to add them. Perhaps the most impactful things we do are on a daily basis - coaching and giving feedback in Daily Huddles and taking corrective action in real-time. Finally, and we are working on this now, get more people involved in collecting data and looking at results. We hope that by including the Falls Prevention team, nurses and others in collecting falls prevention data that they will learn our standards of care and hold both themselves and each other accountable for compliance with those standards.

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