Implementation Process Fall Reduction Project

Fall Reduction Project: An Evaluation of the Implementation Process
Chapter 3: Implementation
In Brief
Blank hospital had a significant increase in falls in the inpatient acute care setting. For this reason, the need for an immutable and comprehensive fall strategy was identified at the hospital following an evaluation of the various costs (both financial and ethical) associated with falls deemed preventable. Towards this end, a fall prevention project was undertaken. I was responsive for overseeing the fall prevention project implementation.
1. Description of Steps
· Pre-implementation phase
· Implementation phase
· Sustainment phase
1.1. Pre-implementation Phase
The pre-implementation phase took a total of 2 months. In essence, pre-implementation phase was meant to prepare the entire facility for the actual phase of implementation. Towards this end, various steps were undertaken. These will be highlighted below.
1.1.1. Identification of Improvement Opportunities
This was founded on the collected fall data. There was an observed increase in the number of falls in the inpatient units. In essence Blank Hospital did not have in place a well-defined fall prevention strategy. There were a number of issues that were identified as contributing significantly to falls. These could be grouped as patient factors and contextual, situational, as well as environmental factors. Patient factors were inclusive of medications impeding orientation, perceptual impairments, orthopedic concerns, muscle weaknesses, and age. On the other hand, contextual, situational, as well as environmental factors were largely inclusive of physical obstacles that further enhance the risk of falls, poor furniture or bed positioning, slow response times to patient alerts, and poor monitoring of patients. In that regard, therefore, a multidisciplinary, multifaceted intervention approach was proposed with the identified areas of concern being leadership and management, human resources, quality assurance processes, communication, physical design, and policy drafting.
1.1.2. Prioritization of Improvement Opportunities
Here, the most critical improvement opportunities were identified. This was particularly important given that an attempt to tackle all the identified issues at the same time was likely to be overwhelming and therefore prone to failure. For this reason, only a few interventions were identified as being worthy of immediate attention. The identified areas of concern that were taken into consideration on this front were inclusive of
· Leadership and management
· Human resources
The implementation team met twice a week for a period of 1 month to fine-tune prioritizing opportunities.
1.1.3. Action Plan Refinement
Following the identification and the prioritization of opportunities for improvement, the action plan was further refined. The following items were assessed:
· Sensitize management on the need for change
· Identify and address the gaps in staff competency and education
Further, it should also be mentioned that in addition to the two items identified above, the roles and responsibilities of key unit persons were identified and those accountable for implementation monitoring recognized. The specific metrics to be utilized in the assessment of changes in performance were also identified. Effort sustenance mechanisms were also addressed.
1.2. Implementation Phase
The implementation phase took a total of 5 months. In basic terms, this phase was largely focused on the implementation of the two interventions that had been fine-tuned in the action plan.
1.2.1. Sensitize Management on the Need for Change
The relevance of obtaining management support in the implementation of change cannot be overstated. It is important to note that in some instances, the same management/leadership that champions for improved performance in some cases derails change efforts in what appears to be a curious irony. Essentially, this happens through failure on the part of management to advance the necessary support to the change initiatives. It is for this reason that the fall prevention project recognized the relevance of management in this endeavor. The roles of the management in this undertaking have been defined below.
· Commitment of resources: it should be noted that I was fully aware of the fact that for this project to succeed, adequate resources had to be committed. Some of the resources that were needed in this endeavor were inclusive of the more tangible resources like new items and products, and the intangible resources such as education and training time, leadership time for purposes of supporting the implementation efforts, and staff time for deliberations and formulation of the appropriate course of action. The commitment of the said resources was a managerial function. In this case, the management committed sufficient resources at every stage of the fall prevention project.
· Formulation of a steering committee: there was need to develop a link between the management and I. In addition to fast tracking the recommendations made, the steering committee would help in the facilitation as well as proper coordination of the identified courses of action. In this case, the steering committee met every two weeks to hear or deliberate upon the recommendations made.
· It was also recognized that the management would be of great relevance in the management of resistance to change. The fall prevention project called for the adjustment of various procedures and the adoption of new ways of doing things. There were no guarantees that all the key stakeholders would be appreciative of the courses of action adopted.
In seeking to gain the full support of management, I engaged in the following undertakings:
· Demonstration of the necessity of the fall prevention project: in this endeavor, I made use of statistics demonstrating that, amongst other things, falls in the inpatient acute care setting had increased by more than 30% over a two-year period.
· Preparation of the budget and demonstration of the long-term financial implications of preventing patient falls: suggestions were made on how the fall prevention project would be funded. In this case, a suggestion was made to the effect that the reduction in costs associated with patient falls would in the long-term help offset the costs incurred in the implementation of measures to curb patient falls. It is important to note that at present, patient falls that result in injury do not receive any reimbursement from Medicaid/Medicate. Other insurance companies are embracing a similar stance. Essentially, if a fall resulted in the patient extending his stay in the facility, Blank Hospital took a loss for the elongated stay.
· Issuance of regular updates: the management was kept fully aware of all the key factors relating to the project. This was done so as to ensure that the management was fully aware of the fact that it was part and parcel of the fall prevention project.
· Fitting into managerial goals: Blank Hospital already had in place other objectives competing for the same resources that the fall prevention project was after for successful implementation. For this reason, I had to indicate how the fall prevention project would complement some of the other key hospital goals and objectives. More specifically, the fall prevention project was tied to the hospital’s objective of providing a safe and therapeutic environment that supports patient treatment and continued wellbeing.
1.2.2. Identify and Address the Gaps in Staff Competency and Education
Measurement of nurses’ knowledge as well as capabilities in fall prevention revealed the need for training. In this case, it was found that for training to be effective, it had to be integrated with the prevailing work routines. The full implementation of fall precautions called for the training and retraining of all hospital staff that interacted closely with patients. I felt that the only way for the fall prevention measures to be embedded deeply into the culture of Blake Hospital was via effective and comprehensive employee training on fall prevention. Towards this end, training focused on the following three areas:
· Fall risk assessment
· Adherence to the fall prevention strategies/approaches
· Identification of the steps to take in case a fall occurs
1.2.2.1. Fall Risk Assessment
· Medication fall risk assessment: pharmacists were introduced into the Medication fall Risk Score with an intention of ensuring that are capable of assessing hospital patients’ medication-related risk factors for falls. In seeking to determine if a patient is at risk for falls so that care can be planned as appropriate, the tool was utilized alongside a nursing risk scale and a clinical assessment.
· Fall risk factors identification: staff nurses were introduced to the Morse Fall Scale for Identifying Fall Risk Factors. This is an important tool for the identification of hospitalized patients’ risk factors for falls. It is important to note that in seeking to predict future falls, the total scores gathered in this case can be utilized. Staff nurses were instructed on how to plan care using the risk factors identified using the scale – with the said planning meant to address the risk factors identified. It should also be noted that in seeking to determine a patient’s fall risk, and thus make the relevant plans, staff nurses were instructed to utilize the tool in conjunction with not only a medications review, but also the clinical assessment.
1.2.2.2. Adherence to the Fall Prevention Practices
Fall prevention could be a rather complex undertaking. The implementation team came to the realization that hospital staff that interacted closely with patients had to be familiarized with the appropriate fall prevention practices. Towards this end, the fall prevention activities that were deemed necessary have been highlighted below:
· Standardized fall precautions: standardized fall precautions were anchored on the risk assessment of individual patients. Towards this end, hospital staff members that interacted closely with patients were instructed on how to develop an individualized care plan on the basis of the assessments. This was done with the full realization that patients do not possess the same risk factor combinations.
· Universal fall precautions: it is important to note that despite Blank Hospital having sensitized its staff on standardized fall precautions, the hospital’s fall prevention program was largely founded on the universal fall precautions. This constituted the bulk of staff instruction. In this case, all hospital staff members who come into constant contact with patients were trained – with the overriding intention in this case being to ensure that the universal fall precautions became part and parcel of Blank Hospital’s culture. It should be noted that the universal fall precautions largely revolved around ensuring that the patient’s environment was not only safe but also confortable. The fall precautions most emphasized in the case of Blank Hospital were adapted from the guideline of the Institute for Clinical Symptoms Improvement.
1.2.2.3. Identification of the Steps to Take in Case a Fall Occurs
Even with the best patient fall prevention strategies or approaches in place, it was apparent that Blank Hospital could still encounter patient fall incidences – albeit at a significantly lower rate. Hospital staff in close contact with patients were instructed on the steps to be taken in the event of a fall/ or in response to a patient’s fall. These have been highlighted below.
· Assessment: hospital staff members were instructed that the patient ought to be assessed for any injury with no assumptions being made as to the extent of the said injury. The assessment could be inclusive of cranial nerve checks, pupils and orientation, cognitive changes, etc.
· Notification of the relevant parties: hospital staff members were instructed to notify the physician, key staff in the patient’s unit, and family members. The relevance of notifying key staff in the patient’s unit could be overstated given the need to ensure that a second fall did not occur.
· Reassessment and monitoring: upon returning to bed, hospital members of staff were instructed on the need to conduct various checks on the patient, i.e. vital sign checks.
· Fall documentation: staff members were notified of the need to document the fall. This they were told is important so as to ensure that the patient is advanced the relevant medical attention and care. The components that were identified as being of relevance on this front included any meaningful observations made, interventions, as well as patient statements.
2. Discussion of Changes
(No significant changes were made to the original plan)
3. Discussion of Barriers
Barrier 1: at first instance, I found it difficult to convince organizational members of the relevance of the fall prevention project. This is more so the case given that despite there being a significant increase in fall rates, no documentation of adverse events was available, i.e. a legal action. For this reason, the fall prevention program did not appear to be a priority.
Barrier 2: next, senior administrative leadership was reluctant to support the program at first. Although it did appreciate the relevance of the program, it did not deem the new fall prevention practices as an urgent undertaking that was in need of immediate intervention. This is more so the case given that the program was essentially competing for resources with other undertakings that were considered to be of greater urgency.
4. Explanation of Overcoming Barriers
I overcame the first barrier by way of creating awareness of the need for a fall prevention program. Towards this end, the clinical benefits of the program were cited.
I overcame the second barrier by presenting a strong and compelling business/economic case for the fall prevention project. A suggestion was made to the effect that the reduction in costs associated with patient falls would in the long-term help offset the costs incurred in the implementation of measures to curb patient falls.
5. Identification of Inter-Professional Relationships
Some of those who were instrumental in the implementation of my project include my nurse preceptor, pharmacist, RNs, physical/occupational therapist, and the senior administrative leadership.
6. Discussion of Relationships
My nurse preceptor provided guidance and advice through the project. The senior administrative leadership was supportive of the project and provided adequate resources to ensure its success. On the other hand, the pharmacist was instrumental for purposes of review and suggestion of alternative medications on the basis of the risk profile of patients. While the RNs were to be responsible for the documentation of not only fall risk assessments, but also prevention and care undertakings; physical/occupational therapist was to be instrumental in the further enhancement of patients’ ability to perform while at the same time being responsible for the issuance of guidelines and recommendations on both equipment adaptation and utilization of assistive devices.
Chapter 4: Post Project Considerations
7. Discussion of Successes
Success 1: one of the most successful aspects of the project was managing to garner the support of both senior administrative leadership and organizational members. This is more so the case given that while the project was appreciated across the board; it was not deemed a priority. Constant engagement of those involved, excellent presentation of all the relevant facts, as well as highlighting of all the relevant benefits of the project came in handy in this endeavor.
Success 2: the other successful aspect of the project was minimization of resistance to change. It should be noted that the project was not in any way slowed down or undermined by resistance to change. This is particularly the case given that I took deliberate measures to ensure that all stakeholders to the initiative were brought on board from the onset. The need for a fall reduction or prevention strategy was communicated in an efficient manner – which effectively lead to the creation of a supportive working environment.
8. How Successes Will Inform Future Projects
Key lessons were learnt from the various successes highlighted above. These are inclusive of:
· The need to actively involve management from project design all the way to implementation
· The need to effectively communicate the details of change to the relevant stakeholders so as to minimize resistance to change arising from lack of familiarity with a project.
9. Aspects that Did Not Go Well
There are various aspects of this undertaking that did not go as had been anticipated. To begin with, I had anticipated that given the availability of data clearly indicating that patent falls had been on the rise within the last two years, the top leadership of the hospital and organizational members did not view the fall prevention project as a priority. This came as a surprise. Secondly, the project took longer than had been anticipated.
10. Understanding What Did Not Go Well
On the basis of aspects that did not go well, I learnt that surveys could in some instances come in handy in seeking to gauge the general feelings within the organization regarding upcoming change efforts. In assessing people’s perception of change it would be possible to craft meaningful interventions to further enhance the change initiative’s chances of success. Contingency planning is also of great relevance. This is more so the case given that in some instances, change efforts may not necessarily turn out as exactly planned.
11. Supporting the Plan
After implementation, the other equally difficult task would be ensuring that the fall prevention program becomes part and parcel of the hospital’s organizational culture. This would entail ensuring that the said program is woven into Blank Hospital’s operational fabric so that its long-term survival is not threatened. Towards this end the following measures were undertaken:
· Identification of those charged with the sustenance of active fall prevention efforts. In this case, a fall prevention committee will be established with the mandate of overseeing the program going forward. This is the team that I will be handing over to. The team is critical in ensuring that fall prevention is an ongoing undertaking.
· Continuous monitoring of fall rates. This is particularly important so as to identify deviations from the intended outcomes so that corrective action can be undertaken.
· Reinforcement of desired outcomes.
12. Abstract Creation
Preventable patient falls are commonplace in most health care facilities. The consequences of the said falls could be immense. In addition to causing head trauma, patient falls could also cause bone fractures and in some extreme cases, even demise. Even in those instances whereby there are no significant injuries associated with a fall, the hospital’s credibility and perceptions of institutional care quality could be severely injured as preventable falls are indicative of failure on the part of the hospital to implement a fall prevention strategy. The problem identified was failure by Blank Hospital to have in place an immutable and comprehensive fall prevention strategy despite the falls in the inpatient acute care setting having increased by over 30% since 2017. Thus, following the identification and the prioritization of opportunities for improvement, the management was roped in and briefed on the need for change so as to garner its support and cooperation. Further, gaps in staff competency and education were identified and a way of addressing them defined. The implementation of the interventions highlighted was largely smooth, save for a few concerns which were promptly addressed. A fall prevention committee will be established with the mandate of overseeing the program going forward.