EBP – SECTION F: IMPLEMENTATION PLAN 1

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Evidence-Based Practice – Section F: Implementation Plan

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Lori Jaramillo

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Grand Canyon University: NUR-699
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May 18, 2016
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 EBP – Section F: Implementation Plan 2

Implementation Plan

Implementing a change within a healthcare organization encompasses many different

aspects. There are different phases, different people, different obstacles or barriers, as well as

different drivers. The purpose of this paper is to describe the methods used to implement the

Hester Davis Scale for Falls Risk Assessment (HDS).

The HDS pilot is taking place at Kaiser Permanente, Downey Medical Center on unit 4

West (the orthopedic/medical surgical unit). The setting will be in an acute care setting on a

medical surgical unit. Consent to use the falls mats and bed and chair alarms are not required, as

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there are no invasive interventions or treatments. Educating the patient includes explanation of

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the care plan interventions.

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Being that this pilot is broken into phases, there is no specific timeframe to complete each
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phase. Phase 1, the initial roll out, was begun in December, 2015 and completed on April 4,

2016. That was four and a half months. Phase 2 began on April 5, 2016. It will be refined, as
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needed, based on the metrics on documentation and falls or falls with injury, as well as
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observation of the staff’s compliance with the use of the care plans’ interventions. Phase 3 will

begin once phase 2 is complete.

During the pilot and training phases, Hester Davis will not charge for use of the HDS

tool. However, there are licensing fees associated with the HDS (no discussion at this time). As
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for the tools to be used with the interventions, there is the falls mat, chair alarms, and bed alarms.
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All of the beds on the orthopedic/medical surgical unit have bed alarms. The staff must be

trained the appropriate alarms to place on the beds. The chair alarms are being provided by Posey
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for testing purposes. Currently, KP is working with two different vendors in regards to the floor

mats. There is no contract with any of the vendors, in place, at this time, so everything is

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 EBP – Section F: Implementation Plan 3

currently on loan for the purpose of the pilot. Getting a contract in place with Region takes some

time, so this is something that will be address at a later time. Amy Hester and her team are

available by phone, and we have a standing weekly Webex meeting on Thursdays at 4 pm.

Nursing staff is also needed to ensure proper roll out.

Methods used to monitor the implementation are documentation in the HDS in

EPIC/Health Connect (KP’s electronic medical records), Stat It reports (Risk Management Falls

metrics) and observation. Health Connect/EPIC is where staff documents their assessments on

their patients. Monitoring 4 West staff documentation randomly will provide information about

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HDS documentation, as well as the care plan interventions (use of bed or chair alarms and floor

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mats). Stat It reports are generated and sent every time a UOR (Unusual Occurrence Report) is

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completed after a fall. Monitoring these and reaching out to the unit, if a fall occurs on the unit
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will give more detailed information about the fall. Lastly, random observations will show who is

actually using the interventions recommended in the care plans.

Initially, the champions will be trained on proper documentation in the HDS and the
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correct interventions set forth in the care plans. A computer generated training program has been

put in place in KP Learn (a computer program that is used for training purposes). The staff is
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asked to review the education and the champions will walk the floor to assist the staff with

training, as well. Staff have been introduced to the chair alarm and the fall mats, are aware about
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where they are stored and have been taught how and when to use both.
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The CIS (Clinical Information Specialist), Stella, is responsible for monitoring of all falls

within the medical center and creating a spreadsheet that provides detailed information that could
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have contributed to the fall. As for the Stat It reports, these are generated when a fall takes place

and will be monitored by Risk Management and the Improvement Advisor, overseeing the

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 EBP – Section F: Implementation Plan 4

project. Both of the reports are shared and discussed during the weekly Webex among all the key

stakeholders.

Through training of the champions, the department administrators are hoping to mitigate

any barriers. Through the weekly Webex meetings, potential barriers or challenges are addressed

and answers are provided by Amy Hester and her team on how to address those potential

barriers. The most important aspect of any change process is to be honest and forthcoming with

information.

This implementation plan is feasible. At this time, the increased costs are associated with

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the nursing staff champions. These individuals are hourly staff and for every hour they are

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training rather than working the floor, those are additional fees. Being that the champions have a

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huge role, their hours and fees associated with the trainings have been pre-approved.
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The pilot is just that: a practice of the change project. So, based on the information found

during the process, these small tests of change will be re-evaluated and changes will be made
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based on the information. In order to sustain the changes, a dashboard will be created in Health
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Connect/EPIC to see if everyone on the unit, then the floors, are documenting on HDS. The

dashboard will advise the managers and charge nurses as to who is documenting properly.
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 EBP – Section F: Implementation Plan 5

References

Agency for Healthcare Research and Quality (ahrq). (2014). Never Events. Retrieved from

https://psnet.ahrq.gov/primers/primer/3/never-events

Brown, C.G. (2014). The Iowa model of evidence-based practice to promote quality care: An

illustrated example in oncology nursing. Clinical Journal of Oncology Nursing, 18(2):

157-9. Retrieved from

http://search.proquest.com/openview/68c6cc558c8cabfd155e5c10648895fc/1?pq-

origsite=gscholar&cbl=33118

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Cummins, R. (2015). Patient falls: First predict, then prevent. University of Mississippi Medical

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Center. Retrieved from

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https://www.umc.edu/News_and_Publications/Press_Release/2015-02-23-
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00_Patient_falls__First_predict,_then_prevent.aspx

Dupins, K. (2014). Falls and frailty: Finding who is at risk and keeping them safe. UAMS
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Journal. Retrieved from http://journal.uams.edu/article/falls-and-frailty-finding-whos-at-

risk-and-keeping-them-safe/

Hester, A.L. and Davis, D.M. (2013). Validation of the Hester Davis scale for falls risk
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assessment in neurosciences population. Journal of Neuroscience, 45(5): 298-305.

Retrieved from
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http://journals.lww.com/jnnonline/Abstract/2013/10000/Validation_of_the_Hester_Davis
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_Scale_for_Fall_Risk.8.aspx
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