Reducing Patient Falls at the VA: A Change Initiative

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).

Costs Associated with Patient Falls

The costs associated with these largely preventable injuries are staggering. Even falls that result in only minor injuries cost an average of an additional $3,500 per fall per patient per year, and patients who experience two falls without serious injuries have an average increased annual cost of $16,500 per patient (Neily et al., 2015). The costs of a single fall with a serious injury average approximately $27,500 per patient, and it is clear that these costs detract from resources otherwise available for patient care. Taken together, it is reasonable to conclude that the VA is spending tens of millions of dollars of scarce taxpayer funds each year on patient injuries that could have been prevented.

A number of fall-prevention initiatives have been proposed and implemented by VA leadership in recent years, but these initiatives require both additional resources and buy-in from a multidisciplinary health care team in order to be more effective at reducing patient fall rates (Neily et al., 2015). The VA's leadership faces several obstacles in implementing changes to existing patient fall protocols — most notably the timing of proposed initiatives, the additional work involved (particularly during the transition period), the changes to daily routines and health care practices, and the perception of a loss of control over long-established protocols (Ryan, 2018).

Proposed Change Initiative and Implementation Steps

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 the change initiative, they can and should be assisted by others in its implementation and administration (Sallie-Dosunmu & Wilson, 2018).

The next step in implementing the change initiative is to establish measurable goals in order to determine whether it is achieving its intended results (Neily et al., 2015). These goals can relate to relatively straightforward efforts to reduce the severity of patient falls, such as using self-locking wheelchairs, minimizing the use of restraints to the maximum extent possible, eliminating sharp edges, and installing floor mats and additional grab bars in high-risk patient fall areas (Neily et al., 2015). Other strategies may require cross-disciplinary collaboration, but the focus should remain on identifying viable approaches to reducing patient falls and the injuries they cause.

It is also vitally important to ensure that all stakeholders — including nursing supervisors and staff, as well as other members of the multidisciplinary team — are provided the opportunity to share their opinions concerning proposed changes. In addition, change initiatives should be timed to avoid placing undue burdens on staff during periods of historically heavy workloads, such as preparations for international accreditation inspections from organizations such as the Joint Commission. Finally, unwavering, strong support for the change agent from each organization's top leadership is essential to sustaining any progress achieved and for identifying additional opportunities for improvement (Butt & Nawab, 2018).

In sum, the VA — like all other health care organizations — faces a serious problem that adversely affects the quality of the health care services it provides, and that demands effective leadership to guide the changes required to effect and sustain meaningful improvement across this massive, nationwide organization. These types of efforts are congruent with the guidance provided by Borkoski (2016), who advises: "Today's health care managers are being challenged to redesign the industry to deliver patient-centered, value-based care" (p. 13).

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.