Short Success Stories
Secured Nationally Recognized Speakers for 2023 Annual Summit
Team successfully secured three nationally recognized speakers in Post Acute Care environment. Dr. Arif Nazir recent past president of AMDA; Jennifer LaBay, Curriculum and Education Coordinator for AAPACN; and Joel VanEaton, VP of Regulatory Affairs for Broad River Rehab.
Hearing Great Things
Qsource received correspondence from a facility Director of Wound Management stating the facilities that participated in the reduction of Pressure Injuries for the year 3 CSC Project reported the TA Calls were informative & aided in the prevention of PI.
Successful Reduction in Falls
CSC Project facility reduced falls from 18.5% to 8.1% during 3pm-8pm shift by implementation of successful interventions during the targeted period.
Surpassing Project Goal
Implemented 6 interventions for falls starting when resident admitted to facility and throughout stay. Decreased resident falls in one month by almost 40% surpassing project goal of 10% decrease. Every new admission/re-admit, resident put on bowel/bladder program for 72 hours and then reviewed for toileting plan. An order in MAR for nurses to check on resident every 4 hours the first 72 hours. Leadership rounds during busy times of day and times when falls occur also assisted in positive changes.
Successful Reduction of Falls
At the beginning of the CSC Project, facility fall rate was 22%. Currently, fall rate is 20% with goal being 19.8%, and they have had no falls with major injury during project thus far. Interventions included auditing documentation of fall events to ensure all info related to resident fall(s) was captured. Major issue was the same residents were having repeat falls and facility was running out of appropriate interventions due to incomplete fall event reports. Staff re-educated on Fall Prevention/Interventions and Fall event reporting and weekly facility IDT meetings reviewed falls for complete info; wonderful outcome!
Successful Reduction of FA PUs
Facility had 2 FA PUs in February 2023 due to insufficient staff knowledge & wound care process issues. As of 08/10/23, facility has had no new FA PUs since February 2023. Education to staff about importance of turning/repositioning residents and wedges, anti-pressure boots, etc. & changes to wound care process, including MD notifications resulting in modified wound care orders, created a better process for reducing occurrence of PUs for at risk residents.
Quality Improvements Really Works
Administrator, DON, ADON stated decrease in Falls due to CSC initiative PIP; it opened great insight on how Quality really affects facility. Interventions and areas of improvement caused them to place suggestion box for staff to contribute ideas/suggestions for falls bringing an open mode of positive communication between staff and leadership. Also, being persistent in education and re-education of staff on falls.
Greatest Outcomes
DON stated she participated in many CMP initiatives but the CSC initiative on Psychotropics brought the greatest outcomes and increased her knowledge on medications. She pleaded with her Qsource QIA to continue the PIP, working on patient medications. She signed up for year 4 of CSC initiative to continue working on Psychotropics at facility. By completing RCA – Fishbone, 5-Why and determining individual interventions and reviewing medications in depth to determine best outcome for patients. Since implementation, facility has continuously decreased psychotropic medications.
43 Days With Not One Fall
Administrator stated success of the Falls PIP were based on two specific interventions they implemented. First was placing a “Fallen” star beside the resident room entrance. This made staff more conscience of who’s a fall risk and allowing closer monitoring of residents. Second was bringing back communication book at every nurse’s station. This also was reminder to those coming on shift of what was happening and ability to monitor situation more closely. No falls since August 9, 2023, 43 days without one fall! Surpassing goal of decreasing falls by 10%.
Successful Reduction of Falls
Facility had multiple months (5) with no falls with major injury during project. Facility added fall risk tool for identifying trends, continuing to provide education to staff for appropriate transfers, falls/interventions for continued compliance/success.
Successful Reduction of Falls
Facility ended CSC project strong, within 0.2% of fall rate reduction goal. Goal was 19.8%, facility attained fall rate of 20%. Continuous audits of fall event documentation & re-education of staff for appropriate fall interventions contributed to this facility’s success.
Maintained Staffing Ratios
Facility turnover rate near end of CSC project 0%, with goal rate of 2%. Facility addressed excessive CNA call-offs & educated current staff on referral bonus for bringing new employees to work at facility. Administration communicated with facility staff about reasons for these call-offs and found giving CNAs every other weekend off helped with burnout/excess call-offs. More staff appreciation events during all shifts assisted in morale as well.
Maintained Staffing Ratios
Facility’s overall staff turnover goal for CSC project 12.8%, and as of Nov. 2023 sitting at 10%, reduced from baseline of 14.2% at beginning of project. Interventions placed focused on morale-boosting activities, recruitment initiatives, and gaining knowledge from Staff Satisfaction Surveys.
Successful Reduction of Psychotropic Medications
Facility achieved 21% reduction in Antipsychotics as of Nov. 2023, since start of project.
Successful Reduction of Psychotropic Medications
Goal for facility was to reduce Antipsychotic use to 16.6%, and baseline started out at 18.4% for months of Aug/Sept/Oct. Nov. data collection revealed facility accomplished 11.1%, exceeding goal. Educated physician on certain psychotropics and requirements and offered audit tools to ensure a smooth process for GDR’s.