Hospital Fall Prevention Project: Implementation and Evaluation

Overview and Pre-Implementation Planning

The hospital had experienced 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 following an evaluation of the various costs — both financial and ethical — associated with preventable falls. A fall prevention project was undertaken to address this problem, and the author was responsible for overseeing its implementation.

The project unfolded across three phases: a pre-implementation phase, an implementation phase, and a sustainment phase.

Pre-Implementation Phase

The pre-implementation phase lasted two months and was designed to prepare the entire facility for actual implementation.

Identification of Improvement Opportunities

This step was grounded in collected fall data showing an observed increase in falls across inpatient units. The hospital did not have a well-defined fall prevention strategy in place. A number of issues were identified as contributing significantly to falls. These were grouped into two broad categories: patient factors and contextual, situational, and environmental factors.

Patient factors included medications that impeded orientation, perceptual impairments, orthopedic concerns, muscle weakness, and age. Contextual, situational, and environmental factors included physical obstacles that increased fall risk, poor furniture or bed positioning, slow response times to patient alerts, and inadequate patient monitoring. In response, a multidisciplinary, multifaceted intervention approach was proposed. The identified areas of concern included leadership and management, human resources, quality assurance processes, communication, physical design, and policy drafting.

Prioritization of Improvement Opportunities

The most critical improvement opportunities were then identified. Attempting to tackle all identified issues simultaneously was likely to be overwhelming and prone to failure. For this reason, only a few interventions were selected for immediate attention. The areas prioritized were leadership and management, and human resources. The implementation team met twice a week for one month to fine-tune these prioritization decisions.

Action Plan Refinement

Following identification and prioritization, the action plan was further refined. The two primary items assessed were: sensitizing management on the need for change, and identifying and addressing gaps in staff competency and education. In addition, the roles and responsibilities of key unit personnel were defined, and those accountable for monitoring implementation were identified. Specific metrics for assessing changes in performance were established, and effort sustainment mechanisms were addressed.

Securing Management Support

The implementation phase lasted five months and focused primarily on executing the two interventions refined during the action plan stage.

The importance of obtaining management support in implementing change cannot be overstated. In some instances, the very leadership that champions improved performance can inadvertently derail change efforts — typically through failure to provide the necessary support to change initiatives. The fall prevention project therefore recognized management as a critical partner in this endeavor.

Roles of Management

Commitment of resources: For the project to succeed, adequate resources had to be committed. These included tangible resources such as new products and equipment, as well as intangible resources such as education and training time, leadership time for supporting implementation efforts, and staff time for deliberations and planning. The commitment of these resources was a managerial function, and management provided sufficient resources at every stage of the project.

Formation of a steering committee: A steering committee was established to serve as a link between management and the project lead. In addition to expediting recommendations, the committee facilitated and coordinated the identified courses of action. The committee met every two weeks to hear and deliberate on recommendations.

Management of resistance to change: It was recognized that management would play a critical role in managing resistance. The fall prevention project called for the adjustment of various procedures and the adoption of new practices, and there were no guarantees that all key stakeholders would embrace these changes readily.

Strategies for Gaining Management Support

Demonstrating necessity: Statistics were presented showing that falls in the inpatient acute care setting had increased by more than 30% over a two-year period.

Presenting the financial case: A budget was prepared and the long-term financial implications of preventing patient falls were demonstrated. It was proposed that the reduction in costs associated with patient falls would, in the long term, help offset the costs of implementing fall prevention measures. Notably, patient falls resulting in injury do not currently receive reimbursement from Medicaid or Medicare, and other insurers are adopting similar positions. When a fall caused a patient to extend their stay, the hospital absorbed the financial loss for that extended period.

Issuing regular updates: Management was kept fully informed of all key factors relating to the project, ensuring that leadership understood itself to be an integral part of the fall prevention effort.

Aligning with organizational goals: The fall prevention project competed for resources with other hospital objectives. To address this, the project was explicitly tied to the hospital's existing goal of providing a safe and therapeutic environment that supports patient treatment and continued wellbeing.

Staff Training and Fall Prevention Practices

Measurement of nurses' knowledge and capabilities in fall prevention revealed significant training needs. For training to be effective, it had to be integrated with existing work routines. The full implementation of fall precautions required the training and retraining of all hospital staff who interacted closely with patients. The goal was for fall prevention measures to become deeply embedded in the hospital's organizational culture. Training focused on three areas: fall risk assessment, adherence to fall prevention strategies, and identification of steps to take when a fall occurs.

Fall Risk Assessment

Medication fall risk assessment: Pharmacists were introduced to the Medication Fall Risk Score to ensure they could assess patients' medication-related risk factors for falls. The tool was used alongside a nursing risk scale and a clinical assessment to determine whether a patient was at risk, enabling appropriate care planning.

Fall risk factor identification: Staff nurses were introduced to the Morse Fall Scale for identifying fall risk factors — an important tool for identifying risk factors in hospitalized patients. Total scores can be used to predict future falls. Staff nurses were instructed on how to plan care on the basis of the risk factors identified by the scale, and were directed to use the tool in conjunction with a medications review and clinical assessment to determine a patient's fall risk and plan accordingly.

Adherence to Fall Prevention Practices

Fall prevention can be a complex undertaking. The implementation team recognized that hospital staff needed to be thoroughly familiarized with appropriate fall prevention practices. Two categories of fall precautions were addressed:

Standardized fall precautions: These were anchored in the risk assessment of individual patients. Staff members were instructed on how to develop individualized care plans based on assessments, with the recognition that patients do not share the same risk factor combinations.

Universal fall precautions: Although staff were sensitized on standardized precautions, the hospital's fall prevention program was largely founded on universal fall precautions. All staff members who came into constant contact with patients were trained, with the overriding intention of making universal fall precautions part of the hospital's culture. These precautions focused primarily on ensuring that the patient's environment was safe and comfortable. The universal fall precautions emphasized at the hospital were adapted from guidelines issued by the Institute for Clinical Systems Improvement.