Performance Improvement Plan

for Falls Reduction within an

Acute Neuroscience Unit
Lindsey Isla
NGR 6874, OW62 Spring 2014
University of Central Florida

Organization & Problem
Introduction
This performance plan was developed for
implementation within the neuroscience unit of a
full-service medical and surgical acute care center
serving North Central Florida
The organization has established an annual goal fall
rate for each unit of <3.36 patient falls per 1000
patient days
With the release of their 2013 Fall Summary, out of
the fourteen units identified within the report, the
neuroscience unit bore the highest fall rate

Significance of Problem
Patient inpatient falls are a
common issue across many
healthcare facilities (Tschannen,
& Kalisch, 2009).
The reported fall rate in acute
care facilities per 1000 patient
days averages from 1.3 to 8.9
falls, with higher rates occurring
notably in neurology focused
unit bases (Miake-Lye, Hempel,
Ganz, & Shekelle, 2013)
Given the significant trend
occurring within these
neurologic patient populations,
intervention is justified as this
indicates a overwhelming
patient safety concern

Baseline Data
0
2
4
6
8
10
12
14
16
Jan Feb Mar Apr May Jun July Aug Sept Oct Nov
2013 Monthly Neuroscience Fall Numbers
2013 Neuro Fall Rate
*Dec Falls = 0
7.51 Overall for 2013

Organizational Goal < 3.36
Baseline Data
Data captured from January 1, 2013 December 31, 2013
Data collected retrospectively from individual unit fall
audits
The Fall Summary utilized the National Database of
Nursing Quality Indicators (2012) definition of fall as
a an unplanned descent to the floor with or without
injury
Only those events that met the definition criteria were
included
Only those falls documented in this facilitys
electronic health record software system MEDITECH
were included
Potential Strategies
Since the problem of falls in neuroscience units is one
that is not new, research has formed many successful
strategies employed to address the issue
Execution of fall prevention education to the patient and
family, versus physical/environmental interventions alone
(Ryu, Roche, & Brunton, 2009)
Multifactorial programs tailored around patient specific
risk factors (Miake-Lye, Hempel, Ganz, & Shekelle, 2013)
Identification of fall cause in post-fall review (Miake-Lye et
al. 2013)
Overall, evidence consistently displays that the
implementation of various fall prevention interventions
simultaneously in a formalized program procured
greater achievement in decreasing patient falls.


Culture & Change
Management Strategies
Falls reduction is a safety issue, first and foremost!
There are multiple stakeholders in patient safety
Patients, individual nurses, nursing educators,
administrators, physicians, and professional associations
and accrediting agencies (Ballard, 2003)
However, front-line nurses are very invested in patient
safety
The quality of nursing demands a culture of safe practice at
all times (Ballard, 2003)
Non-compliance to preventable safety errors is high risk
for employment termination
Stressing not only detrimental lifestyle costs but also
professional integrity should be applied when
strategizing culture change
Overview of Plan Design
The overall scope and focus
of this plan is to institute a
formalized multifactorial
falls prevention program
within the neuroscience unit
to reach the organizational
goal fall rate of < 3.36
The methodology that is to
be applied to the
implementation of this
performance improvement
project will be the Plan-Do-
Check-Act (PDCA) cycle.
Overview of Plan Design
I. Plan - Formulate strategies and action plans for
improvement
Create a falls prevention team utilizing both existing
leadership and other staff
Use Root Cause Analysis methodology to analyze previous
falls for error (Lee, Mills, & Watts, 2012)
Based off findings, form a DO strategy tailored to
addressing found errors or now high risk factors
Promote the review of individual patient high fall risk
factors, implementation of associated interventions, and
delivery of sufficient education
Employ SMART goal setting (MacLeod, 2012) to develop
monthly check points with overall goal to have Neuro Fall
rate < 3.36, the organizational goal


Overview of Plan Design
II. Do - Implement improvement plans
Carry out Do Strategy from Plan Step
For every high risk factor for each patient, employ
associated safety interventions, supplemented with
both patient and staff education
Be conscious to continuously record results during the
Do step for evaluation in the Check step
Results would be any falls that still occur over each
monthly period
Data can be recorded in the form of a check sheet
(American Society for Quality)



Overview of Plan Design
III. Check Evaluate results from initial implementation
against improvement goals
Are SMART goals being met? If not, why not?
Conduct RCA to explore why not/continued fall
errors
IV. Act Take any needed action to eliminate discrepancies
between initial results and improvement goals
Depending on the data analyzed in the previous step,
new strategies developed from the Check step are
implemented

Overview of
Plan Design
Because of its ability to
provide the checks and
balances needed to safeguard
strategic plan success and
prompting leadership team
activity, the the plan design
very feasible (Lashley &
Clark, 2013)

This performance
improvement plan is
contingent on the ability of
leadership to unite and be a
constant presence in fall
prevention
Cost & Potential Savings
Costs

Project created with the intent to
be of little cost
Fall preventative intervention
items are already routine
purchasing within the units
budget
Main cost would be the extra
time required and wages for
those within the fall prevention
leadership team for meetings
and when providing staff
education
If leadership can be acquired on
a volunteer basis, this cost may
be avoided
Savings

Inpatient falls as secondary injuries are
associated with increased LOS
(Tschannen, & Kalisch, 2009)
In the time the patient had to remain
at the facility, the facility could have
had provided care to two other
patients in the same time period,
losing the potential to make more
revenue
Patients who sustain injuries from
inpatient falls were estimated debited
$4233 more than those who did not fall
(Ryu, Roche, & Brunton, 2009)
If a hospital is found at fault for these
falls, these cost increases do not
include the expenses associated with
long-term rehabilitation outside the
hospital, patients' pain and suffering,
or the costs of lawsuits

In the end, any immediate costs that would be undertaken for implementing this plan
would be essentially negligible next to the amount that could be saved over long term.
Potential Outcomes and
Evaluations
The goal set for this performance improvement plan is to
decrease the fall rate of the neuroscience unit to meet the
<3.36 overall organization goal rate
Evaluate frequently using Weekly and Monthly Fall
Summaries for target goals
Utilize RCA to adjust plan accordingly
Positive progress can be measured in lower fall rate trends
However, for true success is to be achieved, total belief
that patient safety has preserved must exist throughout
the unit
Ask for continual staff feedback on plan progress and
performance
Ask patient for feedback in safe environment perceptions
References
American Society for Quality. (n.d.). Check sheet. Retrieved
from http://asq.org/learn-about-quality/data-collection-
analysis-tools/overview/check-sheet.html
Ballard, K. (2003). Patient safety: a shared responsibility.
Online Journal Of Issues In Nursing, 8(3)
Lashley, G., & Clark, M. (2013). Great tastes in strategic
planning: Kaizen, PDCA, other lean tools are the
ingredients that can drive results. Industrial Engineer, (2).
40.
Lee, A., Mills, P. D., & Watts, B. V. (2012). Using root cause
analysis to reduce falls with injury in the psychiatric unit.
General Hospital Psychiatry, 34(3), 304-311. doi:10.1016/
j.genhosppsych.2011.12.007
References
MacLeod, L. (2012). Making SMART Goals Smarter. Physician
Executive, 38(2), 68-72.
Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013).
Inpatient Fall Prevention Programs as a Patient Safety
Strategy. Annals Of Internal Medicine, 158390-396.
Ryu, Y., Roche, J., & Brunton, M. (2009). Patient and Family
Education for Fall Prevention Involving Patients and
Families in a Fall Prevention Program on a Neuroscience
Unit. Journal Of Nursing Care Quality, 24(3), 243-249. doi:
10.1097/NCQ.0b013e318194fd7
Tschannen, D., & Kalisch, B. (2009). The effect of variations in
nurse staffing on patient length of stay in the acute care
setting. Western Journal Of Nursing Research, 31(2), 153-170.
doi:10.1177/0193945908321701