ASSESSMENT & MANAGEMENT:

Best Practices

 

Why is it that institutions that implement the same CPGs often acquire different outcomes in terms of success? Some institutions are able to significantly lower the rate of falls among their residents while other institutions are barely able to make a difference. In implementing clinical practice guidelines, many organizations have also released guidelines that outline the essential components of a successful CPG implementation in long term care facilities. In what follows, we first discuss the recommendations for successful CPG implementation, followed by two studies which outlined the process some long term care facilities took in order to achieve successful results.

Registered Nurses Association of Ontario Toolkit

Case Examples

1. Implementing the Falls Clinical Practice Guidelines in Long-Term Care: an Exemplary Mode

2. Testing the Feasibility of Implementation of Clinical Practice Guidelines in LTC Facilities

 

Registered Nurses Association of Ontario Toolkit

There is a concern that CPGs are not fully utilized because they are not effectively implemented. Thus, the Registered Nurses Association issued a guideline on how to maximize the potential of CPGs through a well-planned implementation. The guideline recommends 6 essential components of a successful implementation:

1. Find a well-developed, evidence-based CPG
   • Identify whether or not a credible organization or author has already conducted a critical appraisal of the CPG
   • If yes, identify if the process was systematic and rigorous
   • If not, use the AGREE critical appraisal instrument to assess the CPG
     
2. Identify and engage stakeholders
   • Identify the stakeholders who have high influence and highly support the implementation
   • Develop strategies to engage the key stakeholders so you can maximize the potential of their resources
     
3. Assess the environment for readiness for CPG implementation
   • Identify the barriers and facilitators of implementation
   
   
4. Use of implementation strategies
   • Hold interactive educational meetings for all staff
   • Reminders to prompt behaviour change
   • Build consensus among team
   • Enlist local champions and those with authority to supply resources
   • Choose a place with high chance of success to pilot your implementation
   • Be open to adjusting implementation strategies
   • Provide ongoing monitoring and support during the process
   
   
5. Evaluate the implementation process
   • Determine impact of implementation by evaluating the structure, process and outcome of the implementation
   • Potential indicators of structure (what you need to have): organizational stability, equipment, quality assurance mechanisms, qualification and number of staff, patient and family involvement in decisions
   • Potential indicators of process (how to go about it): development of policies and procedures, awareness of CGP, patient and family knowledge and acceptance
   • Potential indicators of outcome (what happens): achievement of targets and goals, Adherence to CPG, satisfaction with care, health outcomes of patients
   • If possible, collect baseline data before implementing the CPG and compare it to data after the implementation
   • Identify any factors that might bias data collection
   
   
6. Identify resource requirements
• Create a budget to finance the implementation and evaluation of the CPG
• Strategies to persuade administration to contribute resources
  
Adapted from: Registered Nurses Association of Ontario (2002). Toolkit: Implementation of Clinical Practice Guidelines. Accessed February 3, 2007. Available at: /www.rnao.org/Storage/12/668_BPG_Toolkit.pdf

The report ends by providing action plan templates/ checklists to help with the implementation process. These will help remind the implementers to complete the necessary activities required for success at each stage of the process.

The full report can be downloaded at the RNAO website at: http://www.rnao.org/Storage/12/668_BPG_Toolkit.pdf

Conditions for Successful Implementation:

 Below are some key conditions for the successful implementation and sustainability of fall prevention programs:

 Todd and Skelton (2004):

• Clearly define responsibilities of all staff
• Educate and include all relevant health and social care professionals as well as family members of residents in the implementation process
• Continuing communication among the interdisciplinary team
• The presence of a professional facilitator to ensure adherence to guidelines and facilitate development
• Clear falls management policies and procedures for all members of the interdisciplinary team

The Geriatric Subcommittee of the Hospital Authority Head Office (2003):

• Support from administration – provide necessary support and resources
• Establishment of a safe environment
• A monitoring system of fall rate and intervention outcome
• Suitable fall screening tool
• Staff training for comprehensive fall prevention strategies
• Availability of interdisciplinary input to assess patients with frequent falls
  

 Public Health Agency of Canada (2005) in their Report on Seniors’ Falls in Canada:

• Address sustainability in the initial planning stages
• Have key champions to show leadership
• Involve a wide range of stakeholders, including local officials, universities, provincial and national organizations, and seniors
• Focus on specific project components rather than the entire program
• Secure funding for a project coordinator
• Hold ‘train the trainer’ initiatives
• Integrate falls projects into the broader goals of the organization

 

References

Public Health Agency of Canada (2005). Report on Seniors’ Falls in Canada. Available on their website at: http://www.phac-aspc.gc.ca/seniors-aines

Registered Nurses Association of Ontario (2002). Toolkit: Implementation of Clinical Practice Guidelines. Accessed February 3, 2007. Available at: http://www.rnao.org/Storage/12/668_BPG_Toolkit.pdf

Resnick, B. and Simpson, M. (2004). Implementing the Falls Clinical Practice Guidelines in Long Term Care: An Exemplary Model. The Director , 12(2):76-81. Abstract available at PubMed.

Resnick, B., Quinn, C., Simpson, M., Baxter, S. (2004). Testing the Feasibility of Implementation of Clinical Practice Guidelines in LTC Facilities. J Am Med Dir Assoc. 5(1):1-8. Abstract available at PubMed.

The Geriatric Subcommittee of HAHO (2003). Guideline for Prevention and Management of Elderly Falls. Accessed February 3, 2007. Available at: http://www.hkgs.org.hk/fallsguideline.pdf

Todd C, Skelton D (2004). What are the main risk factors for falls among older people and what are themost effective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe (Health Evidence Network report; accessed 03/02/2007 at: http://www.euro.who.int/document/E82552.pdf ).

 

Case Examples: Example 1

 

Implementing the Falls Clinical Practice Guidelines in Long-Term Care: An Exemplary Model
B. Resnick and M. Simpson (2004)

 

This is a case study of the implementation of the 1998 Falls Clinical Practice Guidelines by the American Medical Directors Association. It is an outline describing the implementation process of a specific nursing home that was very successful in reducing the number of falls in its facility following the implementation of the falls CPG. By using the guide which provides information on falls risk assessment, evaluation, and management, a series of four forms were developed to help staff in the implementation process. These forms provided a way for staff to evaluate the resident with regards to falls risk assessment, post-fall evaluation, staff guidance in establishing the cause of the fall, and to development of an appropriate plan of care. Individual and cumulative evaluations of falls were considered as well as the outcomes of the implementation process. Process indicators were used to make sure the CPG was being implemented properly. They include viewing patients’ charts to see that the four forms were completed and evidence that interventions were done. The following outlines the 4 steps this particular facility followed to make the implementation of the Falls CPG a success:

Step 1: Education and Encouragement

The first step involved educating the staff about the impact of falls on older adults and about the implementation process. The staff were taught the skills to carry out a falls risk assessment of residents and a comprehensive post falls evaluation. It also involved strengthening their self-efficacy and instilling in them confidence that the program can reduce falls and improve the quality of life of residents. These skills were reviewed and reinforced during walking rounds with the nurse practitioner. Copies of the CPG, a letter outlining the implementation plan, and the assessment form to be completed post fall were also sent to the residents’ physicians.

Step 2: Recognition and Problem Identification

The next step involved carrying out a falls risk assessment for all residents. The assessment was then used to develop an interdisciplinary care plan for each resident depending on their level of fall risk. To make sure this step was completed, copies of these forms were placed in strategic areas in the nurses’ station and an individual was assigned to make copies available.

Step 3: Assessment of the Fall and Evaluation of Cause

This next step was focused on making sure that if a resident falls, the staff completed the resident post-fall evaluation forms. The forms evaluated the causes of the fall such as what the resident was doing at time of the fall, associated medications, environmental concerns, and physical findings post fall. Once these forms were completed, the nurse was instructed to inform the resident’s physician of the fall and give him/her the opportunity to evaluate the resident within 72 hours and complete form 4. The nurse practitioner would check several times a week to make sure that the forms were completed and if not, she would initiate the evaluations. An appropriate plan based on the forms was then developed and implemented for each individual resident (e.g. rearranging furniture, initiation of physical therapy, and change in medication). As well, a falls prevention team consisting of the director of nursing, nurse practitioner, occupational therapist, activities director, and nursing supervisor, met weekly to review each fall that occurred and updated the care plan when the number of falls started to increase.

Step 4: Reaping the benefits and seeing and setting examples

Finally, the last step of the implementation process involved informing staff of the clinical outcomes of the implementation, particularly the number of falls. Families and administrative staff were also informed of the outcomes and encouraged the support the staff.

Results of this case study:

After the implementation of the falls CPG, the number of falls decreased from an average of 31 falls per month down to 14 in the first month of implementation. The Quality Indicators following implementation also improved: the percentage of residents who needed help with activities of daily living decreased from 35% to 28%, infection rates decreased from 18% to 6%, pain rates decreased from 10% to 6%, restraint use decreased from 7% to 5%, and the percentage with pressure sores decreased from 13% to 4%.

The following are the reasons why this facility was so successful in its implementation:

• forms were checked for completeness
• staff nurses held accountable
• director of nursing followed up with any nurses that did not complete the falls forms
• description of falls individually and cumulatively allowed providers to evaluate each fall individually and implement interventions
• changes were made throughout the facility in response to the cumulative evaluation of falls. Examples:
• finding that a high percentage of falls were due to improper footwear resulted in the facility providing non-skid socks for all residents;
• finding that majority of falls occurred in the individuals’ rooms and bathrooms resulted in heightened staff awareness of the need to check up on residents in their rooms frequently; and
• finding that most of falls occurred between 12 noon and 12 midnight led to the exploration of ways the facility can increase evening supervision and activity and to incorporate afternoon naps




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Case Examples: Example 2

Testing the Feasibility of Implementation of Clinical Practice Guidelines in LTC Facilities -- Resnick, B., Quinn, C., Simpson, M., Baxter, S. (2004)

This study looked at the feasibility of implementing the falls CPG by the American Medical Directors Association. It concluded that the implementation of the falls CPG is practical for facilities that voluntarily attempted to implement it and provides some strategies for the implementation process. In this study, 13 facilities implemented the falls CPG and 8 implemented both falls and pain CPG. Process indicator score sheets were used to evaluate whether the guidelines were being implemented at each facility.

The following are the steps the facilities took in the CPG Implementation process (you will notice that the facility discussed above as an exemplary model took exactly these steps):

1. Education and encouragement
• provide overview of CPG and its implementation to all staff
• provide education on making falls risk, assessment and cause of falls, evaluation of falls and developing care plans
• identify high risk residents with a star on their door
  
2. Easing the Pain
   
• establish who will do what: nursing staff will complete risk assessment and record fall event and evaluation immediately post fall
• copies of forms made available by someone
  
3. Seeing and setting
   
• review with staff interventions that resulted in decreased falls
• meet weekly to review all falls and establish care plans
• highlight successes in newsletters
  
4. Reaping the benefits

• provide staff with findings after implementation and praise them for their progress

The Directors of Nursing in each facility were then interviewed about the challenges of implementation, the benefits of implementation, process recommendations, and recommendations for changes. Some of the main challenges stated by the DONs included educating the staff, carryover of training related to guideline implementation, convincing staff of its benefits, dealing with turnover and float pool staff, accountability of all staff, and the workload on assessment and documentation. However, because of the CPG, the DONs also noted evidence of better assessments and documentation, and more importantly, a decrease in falls. The recommendations they suggested were to implement one CPG at a time, meet with staff, and get tools together before beginning the implementation process. The DONs also recommended for changes of the CPG, mainly that the guidelines need to be shorter and more user-friendly. The process should be simplified and if possible, be made into a computerized program. The DONs also mentioned that the presence of champions and a supportive team strongly facilitated the implementation process. Success also depended on the receptiveness of staff to learn new skills and on their motivation. And finally, they noted that the assessment and evaluation forms given to facilities facilitated the implementation process as well.

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