Lucky, or good?

David K. Wessner
President, CEO
Park Nicollet Health Services

Last week at our weekly operations stand up review it was noted that we had gone for 8 days without a patient fall. The concern was that we would "jinx" the result if by talking about it. While the comment was playful and light-hearted, it exposed a deep belief that much of what we do and accomplish is a result of blind luck and that we best not anger the gods of luck if we expect to improve.

As absurd as that interpretation may sound, it describes a cultural norm in health care that is reluctant to design for a perfect outcome for fear that the uncounted uncontrolled variables would frustrate the best efforts of an earnest team.

We've all had those frustrations. The patient that tries to help out his nurse by getting to the bathroom on his own this time, or, a patient who is not identified as a falls risk because they are in the hospital to mend from a fracture from a previous fall and are not considered ambulatory. It's always something.

Lean learning would lead us in a different direction. As each of our teams experience a fall and then asks why 5 times we learn what root causes we can eliminate as a future risk to patient safety. As our leaders encourage those teams to accept no risk as acceptable and design counter-measures that reduce just one risk at a time we begin to drain the swamp.

Examples of counter-measures implemented to prevent falls (provided by Autumn Anderson, RN MS, Director):

• Hourly Rounding: this includes purposeful visits to the patient’s room every hour by the RN or NA and ensuring they are not in pain, do not have to go to the bathroom, are positioned comfortably in bed, and have everything they need within reach. These are the most common reasons hospitalized patients get out of bed without assistance.

• Low Beds: The RNs on all units can place an order for a low bed. This is a rental bed that is delivered by an outside company, however we have a small kanban in CSR with two beds that are immediately available for use. The bed also come with a “gym mat” that goes on the floor in case a patient rolls out of bed. The beds all have alarms built in them that sound when a patient attempts to get out of bed without assistance. These beds are low to the ground for good reason- a person must use their thigh muscles to get out of bed, and the lower you are the more muscle you have to use to get from the sitting to standing position. Falls risk patients typically do not have this leg strength.

• Post-Fall Huddles: These huddles have evolved over the last year, and they now included the 5-Whys process. Huddles occur on the floor after a fall occurs and before the next shift starts. The flying squad RNs facilitate this huddle, and they assist staff and leadership with understanding defects.

• There are currently andons on the door before you enter a patient room. Yellow “falling star” signs indicate a patient is at moderate risk for falling, and red “falling star” signs indicate high falls risk.

• Patients will have a yellow falls sticker on their armband starting 8/24/09, which indicates they are at risk for falling. RNs view armbands when they are giving medications.

• Patients at risk for falling also have the yellow falls sticker on the Kardex, which RNs review and update at the beginning and throughout their shift.

• The Falls Leadership Team communicates is involved with the SAFE from Falls initiative from the MN Hospital Association, and we also communicate with other organizations throughout the United States. This provides us with evidence based practice and educates us on new initiatives that may not be published at this time.

• The Falls Workgroup meets monthly. This workgroup consists of RN representatives from each unit. They have standard work which includes the monthly meeting, auditing patients on their unit for appropriate falls assessment and interventions, collaborating with unit leadership, and providing positive peer feedback or recommendations for improvement.

• There is Visual Daily Management on in the Visual Control Room where Nursing Leadership has daily huddles at 11:30am. This tool keeps track of the date the last fall occurred, the unit it occurred on, the number of days since the last fall, and the record number of days. There is also a Visual Daily Management tool on each unit that keeps track of individual unit information.

• Red slippers (instead of regular grey hospital slippers) are going to be trialed for three months on two units starting 9/1/09. Other facilities in the United States have used this andon for high falls risk patients, however there is a lack of evidence regarding its success.

• Posey sitters for beds and chairs are pads that patients sit on. When a patient attempts to get up on their own, and the weight is taken off of the pad, the alarm sounds.

• Defective shower chairs have been removed from the hospital. It was found that these shower chairs caused three patient falls. We have a new vendor for shower chairs.

• The Falls Leadership Team has a Kaizen Event planned in September that will help us better understand the relationships between falls risk assessment, assistance level, mobility level, and the activity level the clinician orders.

So I would rather be good than lucky, and these sound applications of lean concepts create real safety for our patients.


David K. Wessner
President, CEO

Park Nicollet Health Services
6500 Excelsior Blvd.
St. Louis Park, MN 55426
952-993-5013
david.wessner@parknicollet.com