Objective 1:

Illustrate a data collection process that will provide the opportunity to improve the inter rater reliability when reporting fall data to National Database of Nursing Quality Database (NDNQI).

Objective 2:

Identify the additional benefits such as improve patient safety, education, and peer review that can be derived from implementing an effective review process.

Purpose: Encourage viewers to utilize a "take nothing for granted" approach to evaluating and ensuring the accuracy of data when preparing fall data for submission to the NDNQI that also drives performance improvement activity.

Description of how the session (poster) will provide relevant and current knowledge:

The organization has developed a collaborative approach for analysis of fall data integrity. Historically data from "incident reports" was extracted and aggregated data reported internally. Participation in NDNQI and other external databases required a closer scrutiny of the data integrity. The organization developed a collaborative approach through involvement of the reporting staff, department leaders, Risk Manager and the Clinical Documentation Review (CDR) Nurse.

The process included redesign of the computerized Patient Safety Alert to include all the data elements required by NDNQI be mandatory fields and captured at the time of the fall. Department Leaders and the Risk Manager review the alert for breaks in policy and procedure in the care of the patient and evaluate the risk associated with the fall. The CDR Nurse reviews the data reported for accuracy through comparison to documentation in the medical record, discrepancies are discussed with members of the team. The CDR Nurse is responsible for the data integrity and submission of data to NDNQI.

The CDR Nurse as the coordinator of the data integrity is also able to trend nursing care at data points and report trends concurrently. Availability of timely and accurate data leads to staff feedback on performance and opportunities to develop action plans to improve patient outcomes at the department and organizational levels. An example of how analysis of data led to a peer review process on a unit with rising fall rates will be provided to illustrate the positive outcomes of timely performance data.

Summary of the presentation:

Presents a poster flowcharting the process John Muir Health (Walnut Creek, California) uses to collect and review data relating to patient falls. Illustrate the detail involved in the step-by-step process from the time a patient falls through the reporting of the fall to NDNQI, and how accuracy of data is ensured. Flow process drives discussion and action planning for continuous quality improvement.