Research Paper Graduate 1,691 words

Reducing Patient Falls at the VA: A Change Initiative

~9 min read 6 sections Health · Patient Safety

Abstract

This paper examines the persistent problem of high patient fall rates across U.S. Department of Veterans Affairs (VA) health care facilities, including both inpatient medical centers and outpatient clinics. It estimates that up to 20% of VA inpatients experience at least one fall during hospitalization, generating tens of millions of dollars in preventable costs annually. The paper describes the organizational and human resource management standards relevant to addressing this issue, outlines a structured change initiative — including the assignment of dedicated change agents and the establishment of measurable goals — and explains how quality assurance reporting and stakeholder engagement can sustain improved outcomes. Barriers to change, such as staff complacency, workload pressures, and loss of perceived control, are also addressed.

Key Takeaways

Introduction and the Scope of the Problem: Overview of patient fall risk factors at the VA
Costs Associated with Patient Falls: Financial impact of preventable fall injuries
Proposed Change Initiative and Implementation Steps: Sequenced steps for a VA fall-reduction initiative
Organizational Behavior and HR Management Standards: Relevant standards guiding the change initiative
Maintaining and Sustaining the Change Outcome: Strategies for sustaining fall-reduction progress
Summary and Implications for Future Practice: Key findings and barriers to lasting change

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What makes this paper effective

Uses concrete statistics — such as the 20% inpatient fall rate and per-fall cost estimates — to make the scope of the problem immediately tangible and persuasive.
Connects organizational behavior theory to a real-world federal health care system, grounding abstract management concepts in an identifiable institutional context.
Addresses both the implementation and the sustainability of change, acknowledging human factors such as complacency and resistance that are often overlooked in policy-focused papers.

Key academic technique demonstrated

The paper demonstrates applied problem-solution structure: it quantifies the problem using cited data, maps relevant organizational standards to the issue, proposes a sequenced intervention, and then addresses how gains will be sustained. This mirrors professional health care management reporting and shows how academic frameworks translate into actionable organizational plans.

Structure breakdown

The paper opens with a scope-setting overview of patient falls in VA facilities, then moves through cost analysis, proposed change steps (change agents, measurable goals, stakeholder inclusion), and applicable organizational standards. A separate section addresses sustainability through quality assurance reporting and communication. The paper closes with a summary that revisits major findings and acknowledges structural barriers to change. Citations are APA-formatted throughout.

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Essay 1,691 words

Introduction and the Scope of the Problem

Administrators at the Department of Veterans Affairs (VA) are tasked with ensuring that the organization's workplace is safe and free of dangerous conditions for staff, patients, their family members, and others. Despite aggressive efforts and an ever-increasing budget, the VA is still confronted with inordinately high rates of patient falls in many of its tertiary care medical centers. In this health care environment, even minor falls can have serious effects, including extended hospitalizations, nosocomial infections, and even the deaths of veteran patients. The purpose of this paper is to provide an overview of this current issue at the VA nationwide, including a description of the initiatives that have already been implemented. An explanation of the relevant standards for organizational behavior and human resource management is followed by a discussion of how the proposed initiative will maintain and sustain the change outcome. Finally, a summary of the research and its implications for future practice conclude the paper.

Individuals who are hospitalized are at increased risk of falling for a wide range of reasons. Many patients are heavily sedated at some point during their inpatient stays, and it is readily understandable how these individuals can fall when they attempt to get out of bed — especially without staff or family member assistance. Even patients on a blood thinner or blood pressure medication regimen are at increased risk of falling (Falls prevention for veterans and caregivers, 2019).

Likewise, some patients, especially the elderly, may be disoriented by their unfamiliar surroundings during hospitalization, while in other cases patients may simply trip and fall over electrical cables, medical devices, equipment, or other people. Moreover, even outpatients being treated in the VA's nationwide network of outpatient clinics are at increased risk of falling for many of the same reasons as their hospitalized counterparts (Thomas-Hawkins & Flynn, 2015).

Although precise figures are not available, current estimates by the VA indicate that as many as 20% of all inpatients suffer at least one fall during their inpatient stays (Neily, Quiqley & Essen, 2015). Based on the VA's current treatment of more than 9 million veteran patients each year (VA fast facts, 2019), this rate means that more than 1,800,000 patients experience at least one fall during their treatment. Research to date also indicates that of these 1.8 million patients, between 30% and 50% will suffer a fall with injury, and between 1% and 3% sustain some type of fracture (Neily et al., 2015).

5 Sections Hidden · 915 words

Costs Associated with Patient Falls175 words

The costs associated with these largely preventable injuries are staggering. Even falls that result in only minor injuries cost an average…

Proposed Change Initiative and Implementation Steps270 words

The first step in improving the efficacy of the VA's patient fall-reduction initiatives organization-wide is to assign a change agent at each health care facility who will champion the initiative through to completion and monitor its effectiveness thereafter to ensure it achieves the desired results (Sallie-Dosunmu & Wilson, 2018). Although these individual change agents will bear personal responsibility for overseeing…

Organizational Behavior and HR Management Standards130 words

Applicable standards for organizational behavior and human resource management at the VA that are involved in addressing this change include the overarching focus on delivering the highest quality patient care possible — a fundamental responsibility for all members of a multidisciplinary health care team — as well as the more pragmatic need to reduce the enormous costs associated with patient falls. These two standards are applicable to virtually any change initiative at…

Maintaining and Sustaining the Change Outcome185 words

One of the harsh realities of the human condition is the tendency to become complacent, even when confronted with serious and growing problems such as the prevalence of patient falls. It is entirely possible for health care providers to attribute any…

Summary and Implications for Future Practice155 words

The research showed that despite its best efforts, the U.S. Department of Veterans Affairs continues to experience inordinately high patient fall…

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References

Borkoski, N. (2016). Organizational behavior, theory, and design in healthcare (2nd ed.). Sudbury, MA: Jones & Bartlett.

Butt, F. & Nawab, S. (2018, Summer). Organizational factors and individual effectiveness: Moderating role of change management. Pakistan Journal of Psychological Research, 33(1), 75–79.

Fall prevention for veterans and caregivers. (2019). U.S. Department of Veterans Affairs. Retrieved from https://www.patientsafety.va.gov/veterans/falls.asp.

Morris, Z. H. (2015, April). Any nurse can do it: Sustaining change when volunteering overseas. American Nurse Today, 10(4), 37–39.

Neily, J., Quiqley, P. A., & Essen, K. (2015). Implementation guide for fall injury reduction. Washington, DC: Department of Veterans Affairs.

Ryan, W. (2018, August 28). Six barriers to organizational change and how to overcome them. SJ Leadership. Retrieved from https://sjleadershipcoach.com/2018/08/28/6-barriers-to-organizational-change-and-how-to-overcome-them/.

Sallie-Dosunmu, M. & Wilson, D. C. (2018, April). Are you ready? Bring people along during times of change. Talent Development, 72(4), 102–104.

Thomas-Hawkins, C. & Flynn, L. (2015, April 1). Patient safety culture and nurse-reported adverse events in outpatient hemodialysis units. Research and Theory for Nursing Practice, 29(1), 53–59.

VA fast facts. (2019). U.S. Department of Veterans Affairs. Retrieved from https://www.va.gov/opa/publications/factsheets.asp.

Key Concepts in This Paper

Patient Falls VA Health Care Fall Prevention Change Agent Organizational Change Multidisciplinary Team Patient Safety Quality Assurance Health Care Costs Stakeholder Engagement