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Leadership Strategy AnalysisQuality Improvement ProcessFall PreventionKarin Mogren-KuzmaFerris State UniversityAbstractThe purpose of this paper is to analyze a leadership strategy for a quality improvement process. Patient falls are a commonly occurring adverse event in acute care hospitals, and organizations must be committed to maximize safety and quality by acknowledging weaknesses and by making improvements as needed. The desired outcome for this quality improvement project is to reduce the number of inpatient falls to less than eight per month. Falls result from a complex mix of medical, biological, environmental, and behavioral factors, many of which are preventable (Nystrom & Hellstrom, 2012). Inpatient falls are costly both for the organization and the patient. It has been estimated that 30% of falls in an inpatient setting results in serious injury (Rowe, 2013). Risk factors of falling can be classified as extrinsic or intrinsic. Extrinsic factors are related to the physical environment whereas intrinsic risk factors involve impairments of gait or vision, dizziness, or medication use (Nystrom & Hellstrom, 2012). Causes of falls are multifactorial and must therefore involve several disciplines within the organization to achieve the quality improvement goal. The nursing director, managers, nurses, nursing assistants, physical therapists and maintenance engineers are all included in the interdisciplinary team. The tracking tool “Tracking Record for Improving Patient Safety” (TRIPS) will be used for collecting falls data. As for the implementation strategy, Lewin’s theoretical framework of organizational change is used. To evaluate progress and determine if desired outcome were met the Six Sigma model is used.Keywords: Fall prevention, quality improvement, strategy analysis, implementationFall PreventionIn acute care hospitals, patient falls are a commonly occurring adverse event. Optimizing patient outcomes and preventing adverse outcomes from falls is the focus of this quality improvement process. An organization must be committed to maximize safety and quality by acknowledging weaknesses and by making improvements as needed. Yoder-Wises (2011) states that a quality improvement philosophy must shape the healthcare culture in order to identify and improve skills for assessment, measurement, and evaluation of patient care. Accreditation by the Joint Commission is a visible demonstration of a commitment to improving quality care, accountability, and patient safety. Patient safety is one of the key indicators for the accreditation process and has been a benchmark of the Joint Commission. The Joint Commission defines patient safety as “the prevention of harm to patients” and represents a primary principle to all health care organizations, especially hospitals (The Joint Commission, 2013, para. 4). In April 2013, the National Database of Nursing Quality Indicators (NDNQI) made changes regarding fall indicators and definitions of a fall. “A sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can) is considered a fall” (J. Standfest, personal communication, May 24, 2013). The literature recognizes that a majority of falls occur within the first week of hospitalization. With the new stringent definitions and indicators of what constitute a fall, and the data indicating that many falls occur early on in the hospital stay, it is imperative that all patients are assessed for their fall risk on admission and continuously thereafter to prevent falls (Nystrom & Hellstrom, 2012). This quality improvement project is designed to reduce the incident of falls on an acute care stroke unit. By involving interdisciplinary team members, the goal is to improve screening and assessment tools for a comprehensive, ongoing fall assessment. Further prevention and reduction of falls will directly stem from individualizing care plans, monitoring patient responses, and making revisions as needed.Identifying Clinical NeedThe most common danger jeopardizing the health and independence of elderly people is falling. Falls results from a complex mix of medical, biological, environmental, and behavioral factors, many of which are preventable (Nystrom & Hellstrom, 2012). Preventing falls and injuries associated with falls is a goal of many organizations. Fall prevention has according to Rowe, (2013) been an elusive problem to solve. Falls present a serious challenge to quality control and patient safety. It has been estimated that 30% of falls in an inpatient setting results with serious injury, explaining the high financial and human risk associated with falls (Rowe, 2013). A variety of consequences can come from falls, including serious injuries, fractures, reduced quality of life, and increased fear of falling and restriction of activities, isolation, and death. Regarding costs, the consequences of falls can be substantial for the organization as well. According to Centers for Disease Control and Prevention (CDC) in 2010, the U.S. healthcare system spent $30 billion in falls (CDC, 2012, para. 1).Incidences It has been estimated that approximately 2%-17% of hospitalized patients experience a fall during their stay. Furthermore, filed incident and accident reports associated with falls are between 15% and 80% in hospitalized patients. However, fall rates differ depending on hospital setting and size (Rowe, 2013). The circumstance by which patients’ fall varies from hospital setting, but a majority of falls are unwitnessed and occur in patient rooms. Rowe (2013) reports that activities associated with falls included transferring, walking, and bed-related activities. Serious injuries seen in hospitalized patients who fall are 1%-10%. According to Kelly Ewing, resource clinician at Munson Medical Center, the goal is to have less than eight inpatient falls per month. In March, twenty falls were reported, eight of which, resulted in injury. In April, the number of inpatient falls was fourteen, three of which sustained an injury (K. Ewing, personal communication, June 6, 2013).Risk FactorsRisk factors must be assessed in order to determine what patients are at an increased risk of falling. According to Nystrom & Hellstrom (2012) several factors can predict the fall risk. Risk factors can be classified as intrinsic or extrinsic causes. Intrinsic risk factors are further divided into five categories: orthostatic hypotension, visual impairment, impairment of gait or balance, medication use, and cognitive impairment. Extrinsic factors on the other hand, are related to the physical environment such as furnishing, condition of floor, bathtubs and toilets, poor illumination, improper use of ambulation devices, and the condition of footwear (p. 474). The more risk factors the patient has, the greater probability of falling. The necessity of evaluating risk factors and implementing prevention strategies are imperative for nurses and interdisciplinary team members in order to reduce risk, and prevent falls. OutcomesThe desired outcome for this quality improvement project is to reduce the number of inpatient falls to less than eight per month. According to Dykes (2012) in order to prevent falls in a healthcare setting, intervention strategies tailored to specific patient needs and cooperation between multiple disciplines are necessary. A ‘culture of safety’ is a concept originating outside of the healthcare setting, but is very applicable to standards of care in a healthcare organization (Agency for Healthcare Research and Quality [AHRQ], 2012). Developing a culture of safety requires commitment and collaboration across all levels, from staff nurses and aids to managers and physicians. In order to reduce falls and address safety concerns, communication, policy development, and formation of multidisciplinary teams are necessary (AHRQ, 2012). Interdisciplinary TeamAs previously mentioned, causes of falls in inpatient settings are multifactorial and must therefore involve several disciplines within the organization to address areas in need of improvement in order to achieve the set goal. To begin with, organization- wide change must start at the top with managers, administrators, and educators to grant resources, education, and implementation of protocols. The interdisciplinary team of this project will include the nursing director, unit managers, nurses, nursing assistants, physical therapists, and maintenance engineers. In order to succeed, collaboration and communication between team members is essential. The responsibilities of the nursing director and unit managers will be to appoint roles, initiate the program, and monitor progress. Responsibilities also include allocation of resources for staff education and promoting communication between team members. Identification and removal of barriers that prevent team members from completing their tasks as well as ensuring that a blame free environment is upheld is also the responsibility of the nurse managers and the nursing director (AHRQ, 2012). The staff nurses are responsible for implementation of new interventions as well as screening patients for fall risks upon admission and ongoing throughout the patient’s stay. The nurses develop individualized care plans and ensure its implementation among team members. Nursing assistants are responsible for implementing specifics of care plans set forth by nurses, such as toileting schedules, ambulating with assistive devices as well as inspecting the environment and equipment for potential problems. The physical therapist assesses the patient for transfer, mobility, and assistive devices needed and communicates this to the nurse and other team members. The maintenance engineers are responsible for inspecting and repairing equipment as well as reducing environmental factors that could potentially increase risk of fall (Taylor, Parmelee, Brown, & Ouslander, 2005). All interdisciplinary team members are responsible for encouraging patients and their families to ask for assistance when transferring or ambulating. Data Collection MethodThe data collection method will consist of a tracking tool called Tracking Record for Improving Patient Safety (TRIPS) (Taylor et al., 2005). See Appendix A. Taylor et al. (2005) states that using the TRIPS form allows for trending of data, so information about time, location, and type of fall can be identified. Furthermore, the different items to be completed on the form help identify the circumstance of the fall, whether staff was present, the cause of the fall, the activity at the time of the fall, and if assisted devices were used. With this information available, interventions for changes and improvement can be made (Taylor et al., 2005).Strategy ImplementationChange is a natural process towards progression and improvement and it is essential for continual growth of an organization. However, change is not always embraced and it is therefore important to facilitate change as smoothly as possible. A cornerstone model for organizational change was developed by Kurt Lewin, his model of Unfreeze, Change and Refreeze refers to a three stage process of facilitating change (Levasseur, 2001). The first phase, unfreeze, functions by first identifying factors that are in need of change. Elements such as environmental conditions, attitudes, behaviors, barriers, and perceptions must be addressed in order to reduce the number of monthly patient falls. The unfreeze phase determines the number of monthly falls, the staffs’ perception, attitudes, and knowledge regarding unit falls and the consistency in use of fall assessment tools. Assessing the availability of assistive devices and environmental conditions is also done in this phase (Levasseur, 2001). The second phase, change, integrates aggressive fall risk screening, activating bed alarms for patients with identified risk factors, and educating staff regarding falls and preventative interventions. The identified need of improving physical and environmental factors is also implemented in this stage. Quantitative data is collected and used to evaluate the outcome of the implemented changes. As an illustration, education on how to use the Hendrich’s II fall risk assessment tool and implications of the scores are necessary information for all clinical staff. The assessment tool helps identify risk factors for falls such as, confusion, altered elimination, orthostatic hypotension or dizziness, medications, and ambulation limitations. Levasseur (2001) argue that visionary leadership and collaboration between multidisciplinary team members is essential in order to enable the process of change. The third and final phase, refreeze, is the phase where the new concepts and interventions are established and kept consistent. This involves the process of actively working together to maintain, and improve the new system (Levasseur, 2001). Some of the elements include incorporating the new changes into a daily routine and identifying and eliminating barriers in order to sustain change. Ongoing training, support, and positive reinforcement of the new process will create the conditions for a successful change to occur (Levasseur, 2001). EvaluationMeasuring progression of this quality improvement project will be done by evaluating monthly fall reports for improvement, and the achievement of the desired outcome: of less than eight patient falls per month. Analyzing the success of implementation strategies can be done by referring to the quality improvement strategy of Six Sigma. Six Sigma is a five step process based on scientific methods to define, measure, analyze, improve, and control (DMAIC) (Siedl & Newhouse, 2012). The steps of Six Sigma can be applied in their logical order, starting with defining the goals of improvement activities and indentifying stakeholders. The goal is to reduce the amount of falls among hospitalized patients and the stakeholders are the patients as well as the organization. The measure and analyze phase involves the measurement of the current process, descriptive statistics, and performances and weaknesses. This includes a review of documented monthly falls and an evaluation of current fall risk assessment tools and specific interventions to prevent falls and where improvements can be made (Siedl & Newhouse, 2012). The improve phase is the implementation strategy, already defined in this project utilizing the change model by Lewin. The final phase is control. The goal of this phase is to control the future process to minimize flaws, waste, and maximize its benefits. It is critical to implement interventions that will prevent falls and help identify risk factors of falls in order to maximize patient outcomes and reduce hospital costs associated with falls. ??ReferencesAgency for Healthcare Research and Quality. (2012). Patient safety primers. Retrieved from for Disease Control and Prevention. (2012). Home and recreational safety. Retrieved from , P. C. (2012). Adding targeted multiple interventions to standard fall prevention interventions reduces falls in an acute care setting. Evidence Based Nursing, 15(4), 109-110. doi: 10.1136/ebnurs-2012-100630Levasseur, R. E. (2001). People skills: Change management tools - Lewin’s change model. Interfaces, 31(4), 71. Retrieved from , A., & Hellstrom, K. (2012). Fall risk six weeks from onset of stroke and the ability of the prediction of falls in rehabilitation settings tool and motor function to predict falls. Clinical Rehabilitation, 27(5), 473-479. doi: 10.1177/0269215512464703Rowe, J. (2013). Preventing patient falls: What are the factors in hospital settings that help reduce and prevent inpatient falls?. Home Health Care Management, 25(3), 98-103. doi: 10.1177/1084822312467533 Siedl, K. L., & Newhouse, R. P. (2012). The intersection of evidence-based practice with 5 quality improvement methodologies. The Journal of Nursing Administration, 42(6), 299-304. doi: 10.1097/NNA.0b013e31824ccdc9The Joint Commission. (2013). , P. S. (2011). Leading and managing in nursing (5th ed.). St. Louis, MO: Mosby.APPENDIX A ................
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