Project Final Report

General Information:
Project name: Reducing Patient Falls
Project Manager Name: Kimberly Nix
Date of Report: 11-17-14
A. Project Overview: Establishing a falls reduction program is the basis of my project. This
program will not only benefit the patients well-being, but would also improve patient safety. I
believe it is unrealistic to strive for a goal of zero patient falls, I think it is more realistic to set a
goal to reduce the number of patient falls we are experiencing in our facility. Our facility is a
restraint free facility and an Eden certified home which does set some barriers in regards to fall
interventions, however, there are numerous resources that are acceptable in an Eden certified
home. A leader must not dictate change but should continually assess the changing needs of not
only the organization but the individuals employed by them to increase the success of the
organization. A leader must possess qualities that promote a trusting, positive, fair, friendly, and
beneficial relationship between themselves, the staff, and the organization as a whole. Continued
open communication among the leaders and the staff will paint a clear picture of the
organizations goals and mission from all viewpoints. Collaboration among all parties creates
personal and professional stakeholders in the success of not only the organization but the
individual within the organization. When an individual is acknowledged and supported they
become responsible for their environment and the failure of or success of it. This can be a potent
driving force for the individual and the organization. Communication and collaboration can
make or break the success of this project.
http://www.eden.com
B. Project Goal(s) and Objectives/Deliverables:
1. Develop an interdisciplinary team
a. The initial interdisciplinary was formed. I then realized I was missing an iatrical part
of the team; a maintenance representative. He was added immediately after the first
meeting.
2. Develop criteria to identify patients who are at risk for falls. Establish triggers.
a. This goal was met and actually exceeded my expectations.
3. Ensuring adequate supplies are available to make the appropriate interventions.
a. This was probably the most difficult goal to meet. I had to depend on someone else to
complete this goal. We were slightly behind schedule due to the supplies not being
delivered on time. They were 4 days late; however, we remained on time.
3. Education to staff and patients.
a. This was an exciting time for me. I was able to share my enthusiasm with the
patients, staff, and families.
5. Initiate patient fall reduction program.
a. I am happy to report; we were able to implement this project on time.
I think I underestimated how depended the success of this project was in regards to the
communication of the interdisciplinary team. I understand how important communication is
between team members, but the key to communication was effectiveness. I also realized it was
important to include the medical director to be on the team as well. He was reluctant at first, but
then I explained why I felt it was important for him to be on the team, and he agreed. So, after

the first meeting, we had a physician included on our interdisciplinary team. He had a lot of
great ideas and suggestions. The staff was all reeducated on purposeful rounding. The
expectation is that the staff will round on all the patients every hour during the hours of 0600 and
2200 and every two hours during the times of 2200 and 0600. They will ask the patients the 4
Ps; potty, positioning, personal items, and pain. The staff was shocked yet concerned on how
we compared to our sister facilities in regards to how many falls our facility has had since
January 1st, 2014. The patients were educated at our elder council meeting that was held last
week. While not all the patients attended, I made it a point to visit all the patients who did not
attend and gave them the education.
C. Comments: Of course there were some bumps in the road during the implementation of this
project, but it overall went very well. I was really concerned at first with the success of this
project. While we were getting the project underway; we had 3 falls; one with injury. I was
devastated. I had a poor me moment. I then pulled myself together, and said to the team This
is why we need a fall reduction program. I am happy to report; we havent had any falls since
implementation of the program. We really didnt encounter any ethical issues. I think
understanding the teams learning techniques was a minor barrier. I needed to understand
everyones learning style and present the information in a method they would understand. Once
this was accomplished, the team meetings were very successful. Environment is not explicitly
defined but is described as being the larger whole, which is beyond the consciousness of the
individual. The interactions between person and environment create a unique configuration for
each individual. (Tomey & Aligood) Environment includes the spiritual, physical, emotional
and social surroundings that are reflected in areas such as physical beauty, emotional calmness
and harmony in social relationships. The environment also has an effect on human attitudes and
actions that can enhance or hinder its healing capacity. Stop here for one moment and reflect on
your daylook at your work environment, your own perceptions of you as a professional, and
the persons you care for. Is there anything that you can work on today to make any one aspect
better, more efficient, or personal for those you care for tomorrow? A caring leader/manager is
one who works with credibility, integrity, diligence and desires to inspire others. Servant
leadership emphasizes increased service to others, a holistic approach to work, building a sense
of community, and the sharing of power in decision making. Greenleaf wrote that it begins with
the natural feeling that one wants to serve, to serve first. Then conscious choice brings one to
aspire to lead. The difference manifests itself in the care taken by the servant-first to make sure
that other peoples highest-priority needs are being served. The best test: Do those served grow
as persons; do they, while being served, become healthier, wiser, freer, more autonomous, more
likely to become servants? (Spears & Lawrence). As a leader, I do my best to practice servant
leadership every day so that I can create an environment that any health care professional can be
proud to work in and that inspires autonomy and personal/professional growth. As a leader, I
feel it is equally important that I can trust the staff to make decisions and to work with integrity
while keeping the patient, their peers, facility and community in mind.
Tomey, Ann Marriner and Martha Raile Alligood (2006). Nursing Theorists and Their
Works, (6th edition).
Spears, Larry C. and Michele Lawrence (2002). Focus on Leadership: Servant
Leadership For The 21st Century. 3-4.

D. Recommendations from team members, project manager and site representative: The
interdisciplinary team was very open with their opinions and suggestions. Some of the
suggestions were; opening up the team to involve other members of the staff; this suggestion
came from the nurse aide on the team, she felt it was important to involve more front line staff.
The activities coordinator on the team suggested involving hospital volunteers to be engaged
with meal time activities. Our medical director suggested including a pharmacist representative
to discuss mediation options and to review all the medications the patient is on. Involving a
maintenance representative proved to be extremely beneficial. He had a lot of great ideas in
making astatic changes. He also had supplies that we could use that would save the facility
money. I honestly dont know what we could have done differently to make the project more
successful. I do think that adding the medical director and pharmacist to the initial
interdisciplinary team would be beneficial in a future project. The site representative was
extremely pleased with the progress of the project and felt that the facility would really benefit
from a falls reduction program. Caring means taking the time to slow down, listen to the
patients needs or concerns, and being aware of the non-verbal cues. Its a soft, kind voice or a
gentle touch that says I have time for you, Im listening and I care. A caring health care team
gains trust just by humanizing the patient experience.

E. Interdisciplinary Collaboration: See Appendix A. Some of the recommendations from the

interdisciplinary team were to add members from different disciplines. The team was very
comfortable in expressing their concerns and voicing their ideas. The team worked very well
together especially in the area of respect and professionalism.
F. Quality Assurance: I felt I had a very supportive team; especially with my supervisor. She
was always available when I had a question or when I needed advice. I knew this project was
much needed and would definitely improve patient outcomes. I just needed to express my
dedication and commitment. My supervisor was very supportive.
Please see attachment for the site supervisor evaluation.
G. Time log: Please see Appendix B. For the most part, the project was on time and really
didnt hit many road blocks. This project will be ongoing for at least the next year. The amount
thus far spent on this project: 91.5 hours. I wasnt able to complete my time requirements
during the week; I had to put in some weekend time, which gave me an opportunity to connect
with staff and patient families. Time well spent!

Appendix A
Team
Member
K.U

E.S

D.D

Interdisciplinary Team
Job Title &
Education

Skills/Expertise/Strengths Project Specific

tasks/Activities
She has the ability to
Project manager, she will
Director of
lead people with a
oversee the project and
Nurses, RN,
positive attitude and an
ensure the project is on
CMSRN
understanding way.
track. She will be the
Superior clinical
prime communicator in
assessment skills. Many regards to how the project
years of management
is progressing.
leadership skills
Great assessment skills. She is the doer of the
Nursing
Isnt afraid to dig in and
project. Once the decision
Supervisor, RN get things done.
has been made to
Expertise knowledge with implement an intervention,
rules and regulations.
she will ensure it is
completed
Excellent communication She will be the
Denise Docter, skills. She has the ability communicator to the
MSW
to interact with patients
patients and families.
and families positively.

A.A

Activities
Director, B.S

T.H

Certified Nurse
Aide, High
School
Diploma

L.J

Risk
Management
Coordinator

K.D

She has the expertise in

the activities department.

She will develop activities

programs for the patients.

She has the expertise in

hands on patient care.
She plans an important
aspect of the team in
regards to knowing
whats working and what
isnt.
She has the expertise of
developing fish-bone
analysis and RCAs.

She is a iatrical part of the

team knowing how the
flow of the floor is. She
will communicate as to
what is realistic in regards
to interventions.

She has the expertise in

Dietary
the dietary department.
Manager, CDM She also has a great
understanding of the
rules and regulations.

She will take minutes at

each meeting and
schedule the team
meetings. She will
present the analysis she
has completed.
She will assist in
developing meal time
activities and assist in
incorporating them into
meal time.

Appendix B
Timeline Chart
Milestone
Develop an
Interdisciplinary team

Expected Completion
Date
September 29, 2014

Develop criteria to identify

patients who are at risk for
falls. Establish triggers

October 6, 2014

Ensure adequate supplies

are available to make the
appropriate interventions

October 12, 2014

Education to staff and

patients

October 20, 2014

Initiate patient fall

reduction program

October 27, 2014

Actual Completion
Date
The initial team was
developed on time. After
meeting, I added an
additional member that was
originally missed. Including
a representative from our
maintenance department
proved to be instrumental.
This milestone was actually
completed before the
expected completion date.
The team did a fantastic job
in pulling the information
together and implanting the
criteria.
Unfortunately this milestone
was slightly behind
schedule. The supplies we
had ordered were not
delivered on time, no
excuse, but we didnt have
the appropriate supplies
available to meet this
completion date. We did
receive the supplies until
October 16th, so just a few
days behind schedule.
Thankfully we had the
supplies to keep this
milestone on target. The
education went very well and
the families were very
receptive of the program.
I am extremely happy to
report the falls program was
initiated on time! And to
date..
NO PATIENT FALLS!