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Final Track

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The presentation discussed a comprehensive quality improvement initiative to reduce falls-related incidents in a ward by 20% within six months. The initiative involves a dedicated team, including various team members such as nurses, governing bodies, champions, and patients. It is based on person-centered care and organizational safety culture, supported by individual assessment, patient and care involvement, psychological safety, and a system for learning. The goal is to provide tailored interventions for falls prevention and management, involving patients and their families, and creating a culture of safety and continuous improvement. Hello, everyone, and welcome to today's presentation. I'm very excited to share our comprehensive quality improvement initiative, targeting the high rate of falls-related incidents in our ward. Our goal is clear, to reduce these incidents by 20% within the next six months. Achievable? Hell, yes, with a dedicated team comprising of various team members. Remember, makes the dream work. The dream team is required to work collaboratively and includes nurse unit managers, staff development nurses, governing bodies, force champions, quality improvement experts, nurse educators, and obviously, the patients. Well, why all these people? A Schilling Commission in 2017 said that effective clinical governance builds trust amongst the community and healthcare workers by establishing supportive systems for delivery of safe quality care. In well-managed healthcare settings, responsibility for patient safety and care quality is everybody's responsibility. Our initiative is anchored on two primary drivers, person-centered care and organizational safety culture. These drivers are supported by secondary drivers of individual assessment, patient and care involvement, psychological safety, and a system for learning. Person-centered care, as advocated by partnering with consumers in NSQHS 2017 and Albertini and colleagues 2023, emphasizes tailoring falls prevention and management strategies. This approach ensures that identified interventions are specific to each individual's needs. Timely falls risk assessments upon admission and throughout the shifts, as per NSQHS standards, enables the identification of clinical needs contributing to falls, such as delirium, cognitive impairment, hypertension, continence-related issues. This links to safe environment for the delivery of care, one of the pillars for clinical governance in NSQHS 2017, by ensuring that the care environment is conductive to patient safety, including measures to prevent falls and address individual needs promptly. Albertini and colleagues in 2023 advocated for person-centered visiting, which prioritizes individual falls prevention and management strategies. This approach considers the patient's condition, risk, and behavior affecting their falls risk. We will measure its effectiveness by tracking admissions with completed intervention plans involving family or carer input. Patient-centered care planning treats individuals as equal partners in care, ensuring their safety needs are met. This links to partnering with consumers as a pillar of clinical governance by recognizing the importance of involving patients and their families in decision-making processes, thereby promoting transparency, trust, and collaboration in care, as per NSQHS 2017. Organizational culture focuses on falls reduction as an organizational policy with a strategic approach and shared leadership approach. This challenges perceptions that falls are inevitable. This then links to the governance, leadership, and culture pillar of clinical governance in NSQHS 2017. Because the importance of establishing a culture within healthcare organizations that prioritize patient safety and quality improvement initiatives with strong leadership, driving strategic approach, and fostering an MDT environment to address challenges such as falls prevention is important. Psychological safety, a secondary driver involving a collective leadership approach and compassionate leadership at all levels, ensures openness, trustworthiness, and behavior integrity. This enhances psychological safety, which plays a central role in detecting errors and near misses, as suggested by Hunt and colleagues 2021. In a mental health setting, open and candid discussions are clinically necessary due to complexity and ambiguity of many situations, often comprising subjective observations. Our initiative focuses on involving falls champions in quality improvement. This engagement promotes shared learning amongst clinical staff and, of course, the collective role of organizational culture in driving innovation as change, as highlighted by Giffords et al. 2019 and Hunt et al. 2021. This aligns with clinical performance and effectiveness pillar of clinical governance, emphasizing continuous improvement efforts, staff involvement, and organizational learning for enhanced clinical outcomes, as per the NSQHS 2017. Our holistic strategy focuses on individual assessment, patient care involvement, psychological safety, and a learning-orientated culture. By integrating these components, we aim to provide tailored interventions for falls prevention and management, ultimately reducing fall-related incidents by 20 percent within the next six months. Thank you all for listening to the pitch.

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