Running head: QI STRATEGY ANALYSIS: FALL PREVENTION

Quality Improvement Strategy Analysis: Implementing a Fall Prevention Program at Munson Medical Center Kaitlyn Baldwin, William Berlin, Kelly Jones, Oksana Marchenko, Rebekkah Mcconnell, Brandi Miller, and Tracie Strand Ferris State University

QI STRATEGY ANALYSIS: FALL PREVENTION Abstract The necessity for quality and safety improvement saturates health care. Processes that are inefficient and variable, changing case mix of patients, health insurance, differences in provider education and experience, and numerous other factors add complexity to the healthcare system. Low quality of care leads to medical errors. There is a need to improve health care to be more effective, safe, patient-centered, timely, efficient, and equitable. It is vital to adopt different techniques to recognize disorganized, ineffective care, and preventable errors and then to make

necessary corrections to improve the quality of patient care. Quality improvement (QI) involves the continual evaluation of healthcare services to achieve improved patient outcomes, and includes six steps: identify clinical need, assemble a multidisciplinary team, collect data, determine outcomes, implement improvement strategies, and evaluate the process. This paper will analyze the steps of the QI process regarding care for hospitalized patients who are at risk for falls. Several evidence-based strategies and tools for improving care and preventing falls will be explored.

QI STRATEGY ANALYSIS: FALL PREVENTION Quality Improvement Strategy Analysis: Implementing a Fall Prevention Program at Munson Medical Center Patient falls within the hospital setting affect thousands of patients each year. As many

as 33% of adults over the age of 65 years old will experience a fall each year (Castex & Albright, 2010). Of those falls, 20% to 30% will experience a moderate to severe injury. The cost of treating hospitalized patients with fall injuries is approximately $17,500 per case (Castex & Albright, 2010). Nationally, these numbers result in millions of dollars paid for an issue that could potentially be eliminated. Recognizing the need for improved patient safety, national standards and quality indicators have been developed to help hospitals decrease patient falls. Implementing a successful fall prevention program will require a multidisciplinary approach. Using the quality improvement (QI) process, the healthcare team can plan, implement, and evaluate a program to reduce patient falls and improve outcomes. Clinical Need According to Mion et al. (2012), more than one million falls occur annually in the United States. It is estimated that between three and 20% of inpatients fall at least once during their hospitalization, resulting in injuries, increased length of stay, malpractice lawsuits, and more than $4,000 per hospitalization in excess cost (Volz & Swaim, 2013). Falls contribute to functional decline and increased health care use, and cause lasting pain and suffering (Jorgensen, 2011). They also cause psychological problems, like fear of falling, self-doubt, activity avoidance, and loss of confidence that can lead to functional decline even if a patient has never fallen (Jorgensen, 2011). In 2008, the Centers for Medicare and Medicaid Services (CMS) defined falls as a hospital acquired condition that should never occur and no longer reimburses hospitals for the

QI STRATEGY ANALYSIS: FALL PREVENTION

cost of care related to falls (Miller, 2009). Recognizing the impact that falls have on patients and hospitals, the Joint Commission mandated that accredited hospitals initiate a fall reduction program and requires that all hospitalized patients be assessed for fall risk (Volz & Swaim, 2013). Hospitals recognized as Magnet organizations are required to monitor nurse sensitive indicators like fall rates and must exceed the median of national benchmarks to maintain their Magnet status (Volz & Swaim, 2013). A QI project aimed at preventing falls in hospitalized inpatients is therefore of utmost importance. We chose to initiate a fall prevention program at Munson Medical Center (Munson), a 391-bed, non-profit teaching hospital located in Traverse City and serving all of northern lower Michigan (Munson, 2013). As a Magnet facility, Munson is dedicated to providing high quality patient care and supporting excellence and innovations in professional nursing practice. This program will support these values. Multidisciplinary Team By using a multidisciplinary, multimodal approach, a large healthcare organization in the Midwest was able to lower its fall rate per 1,000 patient days from 3.9 in the fourth quarter of 2009 to 1.8 during the third quarter of 2012 (Volz & Swaim, 2013). Upper level management made fall prevention a priority and encouraged all staff (not just nursing) to participate in a comprehensive fall reduction campaign. A multidisciplinary team was formed with representatives from quality management, risk management, patient safety, nursing research, nursing performance improvement, pharmacy, clinical engineering, and the vice presidents of nursing. The multidisciplinary team reviewed hospital fall data, identified areas for improvement, and implemented fall prevention strategies (Volz & Swaim, 2013).

QI STRATEGY ANALYSIS: FALL PREVENTION

Based on this evidence, the fall prevention team at Munson will include individuals from a range of disciplines. The team will be led by a fall prevention coordinator, who will be responsible for gathering, analyzing, and reporting fall data. Unit managers will provide information about specific falls that occur on their units. One staff nurse from each unit will be invited to join the team to share the perspective of floor nurses. Pharmacists will assist with identifying patients at increased risk of falling due to medications, and propose pharmacy interventions to reduce that risk (such as scheduling diuretics earlier in the day). Physical and occupational therapists will help provide education about safe patient transfers. Plant engineering will assist in modifying areas to reduce fall risk, such as installing better lighting and improving room configuration. Risk management will compare hospital interventions with evidence-based practice to update organizational policies. Quality management will provide feedback on documentation to ensure compliance with Joint Commission standards. By using a multidisciplinary approach, Munson hopes reduce fall rates and improve patient outcomes. Data Collection Data collection is an important step in the QI process. Data collection facilitates the analysis and identification of areas that need improvement in the healthcare environment. It is important to integrate patient safety and risk management into the data collection process when evaluating falls in the healthcare environment. Data collection is done with tools used by the multidisciplinary team. Specific data collection tools may include flow charts, line graphs, histograms, Pareto charts, and fishbone diagrams (Folse, 2011). Once specific fall data is collected, it can be presented in tables and figures to illustrate the QI initiative of preventing falls and improving patient safety.

QI STRATEGY ANALYSIS: FALL PREVENTION When determining fall rates, line graphs are an easy way to show the mean fall rate in a specific time frame. Line graphs present data by showing the connection among variables (Folse, 2011, p. 396). A line graph can depict the number of falls that occur in a set time scale like months in a year. This strategy can measure specific success or failure of QI fall reduction interventions. Data is graphed as independent and dependent variables. An example of an independent variable is time. The dependent variable would be the number of falls that occur in a set time frame. If a fall prevention intervention is successful, the number of falls that occur in a set time frame will decrease. Using the line graph allows the team to analyze program effectiveness. Current fall data at Munson is presented in Figure 1. Standards of Care, Quality Indicators, and Outcomes QI teams use established standards of care and quality indicators to develop measurable

patient-centered outcomes (Folse, 2011). Several standards of care exist for fall prevention. The Joint Commission requires accredited hospitals to establish a fall reduction program containing at least two elements: hospitals must assess and manage patient risks for falls and they must implement interventions to reduce falls based on each patients assessed risks (Jorgensen, 2011). In addition to the standards set by the Joint Commission, the Agency for Healthcare Research and Quality (AHRQ) also publishes fall reduction standards in their fall prevention toolkit (Ganz et al., 2013) and nursing handbook (Hughes, 2008). Several quality indicators are also available to measure the impact of fall prevention programs on the quality of patient care. As a Magnet hospital, Munson is required to participate in the National Database of Nursing Quality Indicators (NDNQI) and must exceed the median of national benchmarks in nurse sensitive indicators like fall rates (Volz & Swaim, 2013). The National Quality Forum (2013) endorses several indicators stewarded by various partners

QI STRATEGY ANALYSIS: FALL PREVENTION

pertaining to falls, including those proposed by the American Nurses Association and included in the NDNQI (number of falls per 1,000 patient days and number of falls with injury per 1,000 patient days). CMS (n.d.) also publishes fall data on their national Hospital Compare website. Because Munson participates in the NDNQI, outcomes consistent with Joint Commission and AHRQ standards that reflect the NDNQI indicators were selected (S. Doll, personal communication, October 22, 2013). The fall prevention team wants to reduce fall rates at Munson to be in the top 25% of comparable teaching hospitals. Specific goals are: Reduce the number of falls per 1,000 patient days to 2.02 or fewer. Reduce the number of falls with injury per 1,000 patient days to 0.00 (rounded). Implementation Strategy The QI implementation process is based on research findings and guided by current evidence-based practices. Using an integrative review process, Spoelstra, Given, and Given (2012) evaluated recent research and summarized interventions to prevent falls in the hospital environment. Several factors that contribute to falls include lack of patient and staff education, poor communication, polypharmacy, unsafe use of equipment by patients and staff, environmental constraints (small doorways, lack of handrails, and poor lighting), and bed height (Spoelstra, Given, & Given, 2012). The fall prevention committee will analyze hospital fall data to determine the root causes of falls at Munson. By examining the specific causes of falls, the team can develop a detailed protocol to address fall risk. Effective interventions will consist of basic universal fall precautions, including risk assessments, patient and family education, a culture of safety, and post-fall evaluations (Hempel et al., 2013). Interventions targeted at high-risk patients would include detailed education, medication review, alert signs, safety rounding, bed-exit and personal

QI STRATEGY ANALYSIS: FALL PREVENTION alarms, identification wrist bands, non-skid footwear, proper use of bed rails, low bed heights, moving high-risk patients closer to the nurses station, and use of sitters when appropriate. Delirium avoidance programs, reducing sedative and hypnotic medication, and sustained exercise programs also might be used to decrease the number of falls (Hempel et al., 2013).

The protocol for the fall prevention program will be written to improve patient outcomes. For example, unit managers will report all falls to the QI fall prevention team, which will meet monthly to analyze possible problems or mistakes. By gathering data, the team can determine if why falls occurred. If the findings reveal an issue, decisions can be made that might include reviewing the hospital protocol for those at risk of falling, enhancing communication about fall risk, and developing customized interventions for those at risk of injury from a fall. Communication about changes and improvements is essential (Folse, 2011, p.401). By systematically collecting and reviewing fall data, a strong evidence base to reduce falls in hospitalized patients will be developed. Process Evaluation QI teams constantly evaluate and measure improvements. When outcomes are not met, revisions in the implementation plan are needed (Folse, 2011). Questions that the fall prevention team would evaluate might include the following: Has there been a decline in the number of falls each month? Are the clinical thresholds defined by the QI team being met? If the evaluation process reveals that the thresholds are not being met, there is a good indication that the process is not working appropriately and the plan may need to be altered. When a patient is assessed as being a high fall risk, a fall risk care plan is initiated. There are many ways to prevent falls from occurring, later evaluating if the fall risk care plan has worked. Bed alarms, chair alarms, colored socks, wrist bands, and safety door signs are all

QI STRATEGY ANALYSIS: FALL PREVENTION examples of ways to prevent falls. By continually evaluating patient characteristics, fall risk interventions may be eliminated as the patients condition improves. For example, there were

three studies that examined the use of bed alarms in hospitalized patients and each study showed a reduction in the number of falls between 13% and 20% (Castex & Albright, 2010). When measuring fall program outcomes, quality managers, nurse managers, and staff are integrating charts and graphs, familiar to researchers, into program evaluation at the point of care (Quigley, Neily, Watson, Wright, & Strobel, 2007, Conclusion section, para. 1). Run charts and control charts are two types of tools that visually display program outcomes and allow QI teams to evaluate program effectiveness. Run charts are used to assess process measures, such as percent of staff trained in fall prevention. Alternatively, control charts can include the fall rate plotted by month (Quigley et al., 2007). By using multiple data analysis tools, the fall prevention team can determine if program outcomes are met, allowing the team to improve the QI plan as required (Folse, 2011). Conclusion Implementing a successful quality program to decrease or eliminate patient falls within the hospital setting is an attainable goal. This will include the collaboration of a multidisciplinary team to not only identify areas of need, but work together to implement strategies to decrease the incidence of falls. Strategies and outcomes will be identified and based on current standards of care declared by national recommendations. Lastly, an evaluation process will be essential to achieve the necessary changes to decrease patient falls. This is a national issue that costs healthcare systems millions of dollars as well as affecting the lives of the patients connected to these events.

QI STRATEGY ANALYSIS: FALL PREVENTION References Castex, J., & Albright, M. (2010). A quality improvement project to examine the use of bed alarms on a medical-surgical unit. Retrieved from

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http://academics.ochsner.org/uploadedFiles/Research/Nursing/finalbedalarmposter.PDF Centers for Medicare & Medicaid Services [CMS]. (n.d.). Hospital compare. Retrieved from http://www.medicare.gov/hospitalcompare/search.html Folse, V. N. (2011). Managing quality and risk. In P. S. Yoder-Wise (Ed.), Leading and managing in nursing (5th ed., pp. 389-409). St. Louis, MO: Elsevier Mosby. Ganz, D. A., Huang, C., Saliba, D., Shier, V., Berlowitz, D., Lukas, C. V., Neumann, P. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ Publication No. 13-0015-EF). Rockville, MD: Agency for Healthcare Research and Quality. Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B, Ganz, D. A. (2013). Hospital fall prevention: A systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatric Society, 61, 483-494. doi:10.1111/jgs.12169 Hughes, R. G. (Ed.). (2008). Patient safety and quality: An evidence-based handbook for nurses (AHRQ Publication No. 08-0043). Rockville, MD: Agency for Healthcare Research and Quality. Jorgensen, J. (2011). Reducing patient falls: A call to action [Special supplement]. American Nurse Today, 6(3), 2-3. Miller, A. (2009). Hospital reporting and never events. Medicare Patient Management, 4(3), 20-22.

QI STRATEGY ANALYSIS: FALL PREVENTION Mion, L. C., Chandler, A. M., Waters, T. M., Dietrich, M. S., Kessler, L. A., Miller, S. T., & Shorr, R. I. (2012). Is it possible to identify risks for injurious falls in hospitalized patients? Joint Commission Journal on Quality and Patient Safety, 38, 408-413. Munson Medical Center [Munson]. (2013). About us. Retrieved from http://www.munsonhealthcare.org/AboutMMC National Quality Forum. (2013). Measures, reports & tools. Retrieved from http://www.qualityforum.org/Measures_Reports_Tools.aspx Quigley, P., Neily, P., Watson, M., Wright, M., & Strobel, K. (2007). Measuring fall program outcomes. Online Journal of Issues in Nursing, 12(2). doi:10.3912/OJIN.Vol12No02PPT01 Spoelstra, S. L., Given, B. A., & Given, C. W. (2012). Fall prevention in hospitals: An integrative review. Clinical Nursing Research, 21, 92-112. doi:10.1177/1054773811418106 Volz, T. M., & Swaim, T. J. (2013). Partnering to prevent falls: Using a multimodal multidisciplinary team. Journal of Nursing Administration, 43, 336-341. doi:10.1097/NNA.0b013e3182942c5a

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QI STRATEGY ANALYSIS: FALL PREVENTION

60 50 Number of Falls 40 30 20 10 0 Falls with injury Total Falls Mean Falls with injury Mean Total Falls

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Month (2012)

Figure 1. Total Falls and Falls with Injury by Month at Munson Medical Center