One DHBs Falls Success Story Delivers Benefits For All

25 Sep 2015

South Canterbury Staff enjoy morning tea to celebrate two years without a serious fall.

“One of the real benefits of being a part of the South Island Alliance is that it provides a regular opportunity for members to share experiences, innovations and learnings with other senior staff members from South Island DHBs, and to deliver those messages back to the frontline,” says Mary Gordon, Chair of the South Island Alliance’s Quality and Safety Group. A clear example of this is the recent celebration by South Canterbury DHB’s Assessment, Treatment and Rehabilitation (AT&R) team, which received the attention of the Q&SSLA.

Since a Falls Reduction Project was undertaken in 2013 staff at Timaru Hospital’s Assessment, Treatment and Rehabilitation (AT&R) ward have celebrated over two years without a serious harm fall in the ward.   Their story is one of many being shared with other DHBs through the Quality and Safety group, to help other teams learn from their project and encourage others to participate in similar projects.

Staff at the AT&R department at Timaru Hospital have experienced a major culture shift regarding falls management over the last two years.   Prior to implementation of a falls reduction project in 2013, staff at the ward had limited engagement with falls prevention strategies, assessments lacked a multi-disciplinary team collaboration, there was limited family engagement and education and there was an attitude that falls were inevitable in the patient group that used the service.

Despite these initial barriers and skepticism expressed by staff, the falls prevention project was implemented, working from the “bottom up” with ward staff members making up the core project team.   The team used the “Model for Improvement” approach to implement changes to the ward, which saw all staff involved in trialing interventions and equipment using plan-do-study-act (PDSA) cycles.

Using the PDSA cycles gave the staff the opportunity to feedback and make changes to their plans prior to implementation. A bundle of care was introduced as part of the project, and now two years on the transformations have been notable. As well as having zero serious falls, AT&R staff report that there has been:

  • routine identification of patients at higher risk of falls and those who are at higher risk of harm from falls
  • direction of resources to those who have the highest need
  • no evidence of increased use of safety watches (the constant presence of a staff member to ensure the well-being of the patient)
  • an intentional rounding plan (Care Calling) which is well utilised
  • a heightened awareness of falls risk and interventions and good collaboration as a team to develop individualised patient care plans
  • improved patient and family engagement

AT&R staff, SCDHB and the Board are reportedly very proud of what they have achieved.  They see improved team collaboration, with all team members aware of falls risk and collaboration where ‘falls are everybody’s responsibility’.

“The success achieved by South Canterbury’s AT&R team as a result of implementing its falls reduction project is a great model for other DHBs to learn from and build on. Through the alliance structure we work to enable the success of one DHB to be shared across the region so that we can all deliver the best outcomes for patients and for the system,” said Mary Gordon.



Published on: Friday, September 25th, 2015, under General