Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care, Essay Example

The Quality Improvement Journey

Patient falls are a detriment to patients and may contribute to many serious and potentially life threatening consequences.  A variety to resources must be in place to evaluate patients at risk of falling in order to reduce the likelihood of these events in a timely manner. Quality of care is critical to organizational performance and to promote patient safety to prevent falls, as the Center for Medicare and Medicaid Services (CMS) has identified falls as a Hospital Acquired Condition (HAC) (Quigley & White, 2013). Information regarding falls is limited in spite of their high level of risk; in addition, CMS does not reimburse hospitals for in-patient falls if they are preventable. A team-based approach to falls must be identified and must be accompanied by action plans, nurse sensitive indicators, and team-based approaches.  A team-based approach will be considered to promote performance improvement on a Brain Injury Rehabilitation unit where falls are likely to occur from time to time.

Problem and Mission Statement

The National Quality Forum (NQF) has identified falls a “never event” during a hospital stay.  Falls are associated with increased morbidity and mortality rates and impact reimbursement statistics (Quigley & White, 2013).  The NQF (2013) recently endorsed the American Nurses Association’s (ANA) National Database of Nursing Quality Indicators (NDNQI) to improve patient safety in hospitals, patient fall rate, and patient falls with injury.  Approximately one million falls are recorded in U.S. hospitals every year, according to the Agency for Healthcare Research and Quality (AHRQ). Therefore, falls prevention is a critical priority with respect to patient safety, patient and family satisfaction, quality reputation, and cost reduction. 

Rates of falls over quarterly periods between 2013 and 2014 are reflected in the chart above These statistics reflect a general decline in fall rates across quarters, with a few notable exceptions. One- half of the incidents indicated a fall with injury and injuries did not occur in the other half, requiring a more consistent approach to falls prevention.

The target for a medicine unit is .68 falls with injuries per 1,000 patient days.  The current falls with injury rate on the Brain Injury unit is 1.39 falls per 1,000 patient days.  The current fall with injury rate is above the NDNQI recommendation benchmark for rehabilitation units in similar health care systems; therefore, improving these numbers is a critical need.

A proactive approach, known as prospect analysis, is necessary to prevent problems from occurring (Kelly, 2011). As part of this process, the Failure Mode and Effect Analysis (FEMA) is used to evaluate patient safety.  In the pilot study, managers introduced video monitors to eliminate or decrease the rate of falls and to assess possible technology failures.

Quality Improvement Model

Quigley and White (2013) address the Plan-Do-Study-Act (PDSA), a commonly used improvement model. This emphasizes the PDSA, a four-step cycle that is used to execute change for process improvement or to develop a modified work flow.  The model will provide a testing environment in real-life work settings and serves as a simple tool for accelerating improvement. When adopting a quality improvement model, it is important to have the most qualified individuals to lead the process improvement team.  Typically, team sizes vary and are constructed to provide support to the department as necessary.  Specific aims are established that are time-specific and measurable, define the specific population of patients, and also consider other systems that will be affected.  The team employs quantitative measures to determine if a specific change will transition into actual improvement. Feedback and creativity must be derived from employees, game changers, creative thinkers, and those with significant experience in the field.  A pilot study must be conducted in order to implement a change that will promote falls prevention and determine its success before it should be rolled out to other teams on a larger scale. This requires forward thinking and the ability to recognize improvements, and if the change is unsuccessful, the cycle will resume (Kelly, 2011).The PDSA model was selected because it is simple and easy to apply to any practice setting.

The team also established a modified version of the Morse Fall Score, a new assessment and intervention form, and provided education regarding the form to the end users. In addition, guidelines for consistency in falls prevention for patients and families were created, along with the creation and design of the sitter program.  Video monitoring was also created in order to determine fall occurrences. At this stage, there was significant collaboration with the Delirium and Substance Abuse withdrawal initiatives and the video monitors’ pilot.

 Primary Measurement

The patient falls indicator is designed to identify the rate at which patients fall, the frequency of injury, and how nursing assessments, interventions, and falls are related (NDNQI, 2012). Reported rates include the following: total falls per 1,000 patient days; injury falls per 1,000 patient days, and unassisted falls per 1,000 patient days.  The current rate of falls with injuries prior to the initiative was 1.39 per 1,000 patient days.  However, the national NDNQI benchmark for falls with injuries on a similar BIRD is 0.68 per 1000 patient days.  It is necessary to reach a score of 0 falls per 1,000 patient days by the end of fiscal year 2015.

Strategies for Managing Ethical Dilemmas

A strict code of ethics enables a team to effectively manage ethical issues in an organized manner and also provides a social contract with those who are served, as well as ethical and legal guidance to all members of the profession. In an effort to keep at risk fall patients as safe as possible, the organization implemented video monitoring pilots on some of the units.  These monitors allow a sitter or a care partner to sit in a designated location and monitor patients who are at risk of falling. However, it is important to achieve the utmost ethical support and guidance in the execution of this process in order to prevent dilemmas that could impact the practice environment. All persons must be aware of the video monitoring equipment and when it is used as patients are evaluated  on a continuous basis.

Staffing patterns and infrastructure for acute inpatient settings are necessary in order to promote safer hospital stays.  Tzeng, Yin, and Grunawalt (2008) recognize the importance of one-to-one constant observation versus placing patients at high risk for falls in an observation room staffed by sitters.  Video monitors are currently not available on the ACM; therefore, one-on-one sitters are used to monitor fall risk patients.  Experienced scholarly consultants and members of the hospital safety committees review evidence-based practice regarding video monitors and their relationship to patient safety.  Physically restraining patients to prevent falls is not encouraged in the organization, as the primary objective is to be restraint free as much as possible.  In healthcare practice, a safer environment requires the necessary precautions to prevent accidental injury. In order to achieve success at this level, the team leader must possess  a transformational leadership style with and ethical and moral perspective (Zaccagnini & White 2011).

Team Description

Teams are typically comprised of individuals with special skills or characteristics within a single discipline, across disciplines, across departments, or across organizations, (Kelly, 2011).   The multidisciplinary rehabilitation teammembers must be comfortable discussing safety issues with patients and should recommend preventive approaches to falls and falls with injuries to patients and staff.  Members for each team are chosen based on their background, experience, and contribution to the team environment. The Falls Nurse Coordinator is responsible for full implementation of the program and serves as its clinical champion. This individual is responsible for coordinating the screening of high-risk patients to be included in the program and performs a Morse falls risk assessment for each patient who is selected. Under these conditions, the nurse must evaluate all steps in the response process and coordinate the implementation of individualized care plans. The nurse also facilitates the education and training of all staff, families and patients, and works with the medical director to inform all primary care providers of the program and their roles.  Care partners are responsible for purposeful rounding and sit-one-on-one with patients who have a higher fall risk.  Also, the physical therapist provides assistive equipment for walking and transferring of patients; the pharmacist monitors medications and offers recommendations for administration times or changes; the plant operations officer is responsible for installing hand rails in the halls and throughout the department, and removing hazardous strips on the floor to the restrooms.

Over time, the team has established a foundation of trust and has discovered a means of managing conflict.  The Mental Models management technique was employed to enable the team members to remain invested in the project, particularly as the team made decisions by listening to all suggestions and determining the best perspective that met the requirements, vision and goals of the project.  Clinical outcomes and communication are impacted by this model and its objectives (Kelly, 2011).  Team members must be committed to the project and seek out methods to communicate their ideas to other team members and to recognize the value of their contributions to the team as a whole.  Time is important and sacrifices must be made to provide benefits for the team and to meet their goals. All team members are held accountable for their actions and will be evaluated by other members when actions do not go as planned.        According to Laureate (2011), team members must commit to each other and to the team as a whole.  The notion of accountability and paying attention to the bottom line is critical to team success.  Team conflicts were significant with this project and reflected the need for the team to focus on statistical analyses that introduced an unexpected synergy among members (Laureate, 2011). This group experienced four stages of development, including forming and a high degree of enthusiasm; storming, involving questions and preparing all members; and developing/initiating, involving increased knowledge. This experience was useful in supporting the team’s planning approach and future strategy.

Leadership Qualities

Transformational leadership is critical to this process and reflects the vision, capabilities, values and expertise in order to effectively manage unstable and highly difficult situations. This type of leadership is critical because it promotes a greater ability to improve patient safety within healthcare practice (Kelly, 2011). From the team perspective, this reflects a need to evaluate frustration, anxiety, and conflicts to promote greater confidence and trust among team members. Therefore, this supports the ability to manage unforeseen events in a productive manner. The team leader is knowledgeable of a variety of situations and continues to learn about the surrounding environment and new disciplines. This requires significant work, but it supports a greater sense of belonging and acceptance to achieve the necessary results. The leader must support a specific vision and empower others to support that vision as best as possible. In addition, the leader must delegate tasks as necessary, establish meetings, obtain team feedback, create agendas, and manage team dynamics effectively. For the team leader, quality improvement is critical and requires a commitment to excellence and a laser sharp focus in order to get the job done. Furthermore, the leader’s role will continue to evolve as growth emerges, along with the ability to gain greater comfort with the situation and its overall direction. As this comfort expands, the leader becomes a facilitator rather than a coach and imparts team members to provide answers (Laureate, 2011). In this manner, the team leader is able to work collaboratively to improve communication and achieve the intended goal of creating a falls prevention program.

Formulate EBP and Action Plan to Achieve Improvement Outcomes

For this project, articles related to falls and injury prevention programs were identified using CINAHL and Medline. This supports the use of evidence-based practice and a level of standardization that serves the program well. Prior evidence supports the adoption of interventions that have been successful in the past and those that have not been effective in meeting the intended goals. Upon review of existing research, it was determined that a falls bundle was likely the most effective means of prevention, and this includes an examination of environmental conditions to prevent falls, such as lighting, handrails, and rubber floor mats (AHRQ, 2014).

The team collectively made the decision to implement a falls bundle, a post-fall huddle, improve staff and patient education, promote purposeful rounding, and conduct routine medication reviews. This included the use of members from the interdisciplinary team to promote these objectives.

Three months after project initiation, the primary goal was to educate 50 percent of staff with the intent to decrease falls by 10 percent. An intermediate goal at six months was to educate 75 percent of staff and a 30 percent decrease in falls. The long-term goal at nine months was to educate 100 percent of staff members regarding the falls prevention program. The PDSA model would be used to implement the program and provide a general structure.

Cost-effectiveness of Initiative, Barriers and Improves Outcomes

With an adjustment to 2010 dollars, one fall without serious injury costs hospitals an additional $3,500, and two falls or more without serious injury increase costs by $16,500.  Falls with serious injury are the most expensive, with additional costs of $27,000 per patient  (Wu et al., 2010).  Approximately 30 percent of falls were a direct result of injury (Oliver et.al, 2010).

The cost of initiating a falls prevention program outweighed the cost of the falls themselves.  The results demonstrated that falls with injuries were reported at zero per 1,000 patient days after nine months of implementation of the fall’s prevention program.  The following figure demonstrates the selected model and how it will impact the program’s inception and execution at all levels.

Summarize the Impact of the Team Process

Within the team, identifying the causes of falls was a critical priority, as well as determining why current processes have been unsuccessful. At the organizational level, clinicians, risk managers, and administrators must communicate regarding practical fall rates and what is required to reduce these rates effectively. The team gathered to evaluate existing data from the population and the setting, compared to the NDNQI from the American Nurse Association’s injury fall rates and other nurse-sensitive indicators. This data was relevant because it provided comparisons related to similar facilities, bed size, teaching status, Magnet status, and other indicators.

The primary objectives of the team were identified by the falls nurse coordinator, using the PDSA model to maintain a greater focus on the required tasks. Each meeting was planned to address the goals and objectives of the team, along with the identification of roles and responsibilities. This required a consensus regarding meeting times and frequency of meetings, along with managing meeting absences. Team members were each responsible for taking minutes at different times, sent by the team coordinator via email to other members. During this phase, team members were required to identify areas where change was necessary, and by the fourth month, meetings were held with Plant Operations, a Physical Therapist, and the Financial Officer to address key objectives. The team acquired approval to purchase hand rails and place them throughout the halls, add fall mats to patient rooms, and replace broken alarms. Patient, staff, and visitor education was expanded and promoted by members of the team to promote a more cohesive approach to the project. Fortunately, no additional cost was necessary to implement post-fall huddles and fall bundles. By the sixth month of the program, hand rails, floor mats, and replacement bed alarms were installed as further planning for falls prevention. The team was responsible for collecting data in order to determine if the new initiatives made a difference in the number of falls that were identified. After nine months of the PDSA program, the team believed that the changes made were successful and were prepared to implement the project on a larger scale. At this time, the team was responsible for evaluating new results and if unsuccessful with a larger group, would reevaluate conditions and revisit the cycle as necessary. Figure 2 provides a detailed timeline for the group’s activities and the needs of the project in order to achieve the necessary outcomes of the project in accordance with a desired timeframe.

Figure 2: Plan-D0-Study-Act Timeline

Summary of Team Process in Creating Improvement

The process of establishing an environment in which falls prevention was successful required a high level of consistency in data reporting, measurement, and general analysis. As a result, NDNQI hospitals participating in the program could also track their own processes, including the use of reliable and valid fall risk screening tools. In addition, the use of standardized post-fall analysis and fall rates were identified in order to analyze the overall safety of the program and to determine its overall effectiveness on a clinical scale.

Members of the interdisciplinary team were responsible for evaluating and implementing strategies to promote the prevention of patient falls. The BIRD implementation provided an assessment of the use of assistive devices and the necessity for gait training. In addition, all staff members were responsible for executing the directives of the program at all stages to improve quality of care and to promote greater patient safety. BIRD was also used to identify fall risk scores to establish new parameters for low, moderate, and high risk falls, as well as complementary falls reduction strategies to reduce these risks. On an annual basis, unit level risk scores will be reevaluated, validated, and modified as necessary with the use of the PDSA quality improvement design.

The primary prevention strategies to be considered for this program included environmental safety, thereby implementing new interventions to promote a safe patient care environment. These strategies included patient rounds every 15 minutes, activating bed and chair alarms, turning on all necessary lights, toileting patients on a frequent basis, checking for appropriate lighting in patient care areas, and ensuring that all fall mats are in place. A nurse will be responsible for initiating the BIRD falls prevention strategy, and medication adjustments will be made as necessary to reduce risk factors associated with medication administration.

In the event that a patient fall occurs, the nurse will be responsible for completing a post-fall assessment of the patient’s health status and must notify the physician on call. This requires a patient management plan that will be conducted in accordance with the post fall management guideline or protocol that is in place. If the patient fall results in an injury, it will be necessary for the physician to conduct a post fall assessment and initiate further requirements for the patient that must be executed by the nursing staff. In addition, after a fall has been identified, a post fall huddle will be conducted with staff members, along with a referral of the fall by the nurse to the interdisciplinary team.

The fall team will also assess all factors that contributed to the fall event and its primary causes, which may include the surrounding environment, medications, equipment, and the interventions that were in place when the fall occurred. It is important to communicate any and all recommended interventions and changes to care plans in order to prevent repeat falls and to communicate and document all results related to a referral. Furthermore, the team will continue to meet on a regular basis in order to discuss other means by which the program could be improved and what is required to keep the program sustainable for the foreseeable future.

For each patient fall, an incident report must be completed and filed, and the report will be comprised of information regarding the nature of the patient’s activities at the time of discovery; how the patient responded to the event; an examination of any evidence relating to injury; the location of the incident; the notification of a provider regarding the incident; and the nurse’s response to the incident after it has occurred. In addition, the staff will be recognized for their efforts when they identify areas in which corrective action is taken to prevent future falls, using the safety STAR designation.

It is expected that a culture of safety must be identified and strengthened by strong interdisciplinary teams that include a high level of collaboration and cooperation among nursing leaders, nursing staff members, and those representing other disciplines. It is necessary for the team to apply evidence-based practice methods to improve standardization and to reduce unwanted or unnecessary variation in processes.

It is expected that the leader must be responsible for supporting each team member’s desire to speak up on behalf of a given patient and to determine how to categorize team members and provide a clear vision and purpose regarding team roles and expectations. Team members must provide routine feedback regarding the program and must be able to know how to correct behaviors that do not promote patient safety and act in the best interest of patients at all times. It is expected that open lines of communication will build greater trust among members. This process has its own learning curve, and this will enable leaders to gain wisdom from errors in judgment and to implement a continuous improvement approach to improve performance.

It is believed that a safe culture will view errors as system failures rather than individual failures (Beaudin & Pelletier, 2012). This requires an understanding of the team dynamic and how to place a greater focus on patient-centered care that is always safe and is of the highest possible quality where patients and family members are put first. The transformational leadership structure will serve this team will and will provide guidance, feedback, and support in meeting specific goals and objectives, while also serving as role models in the process. It is recommended that the team will complete the fall and fall with injury aggregated review on a six-month basis. In addition, an individual root cause analysis will be conducted for any falls or falls that occur with injury. All falls reported by the team will be added to the “lessons learned” database so that others will be able to learn these lessons in future teams. This section of the database will be used to provide other staff members with information regarding prior errors and near misses related to patient falls.

Conclusion

The prevention of falls is a core responsibility of all employees in the healthcare environment. Therefore, communication must be clear and concise regarding these events. The successful implementation of a falls prevention initiative to improve quality requires coordination with providers and collaboration at all levels. This prevention strategy supports communication, teamwork, and collaboration to produce evidence-based quality improvement outcomes.  Staff should not be “blamed or shamed” when a patient experiences a fall; rather, the system failure should be examined with a team-based approach to correct errors and solve problems.

When falls occur, they must be accurately recorded. All staff members must receive routine guidance regarding their professional performance in this area.  Therefore, monthly reports emphasizing fall-related events should be shared by the administration, and staff feedback must be obtained in order to make program improvements.  Strong leadership is essential to promote a successful culture of safety, and the primary role of leadership is to facilitate safety and to establish clearly defined safety policies and guidelines, using falls prevention as a means of promoting change.

References

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