Hospital-Based Fall Program Measurement and Improvement in High Reliability

Organizations
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Patricia A. Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP

Susan V. White, PhD, RN, CPHQ, FNAHQ, NEA-BC
Abstract
Falls and fall injuries in hospitals are the most frequently reported adverse event among
adults in the inpatient setting. Advancing measurement and improvement around falls
prevention in the hospital is important as falls are a nurse sensitive measure and nurses
play a key role in this component of patient care. A framework for applying the concepts
of high reliability organizations to falls prevention programs is described, including
discussion of the core characteristics of such a model and determining the impact at the
patient, unit, and organizational level. This article showcases the components of a patient
safety culture and the integration of these components with fall prevention, the role of
nurses, and high reliability.
Citation: Quigley, P., White, S., (May 31, 2013) "Hospital-Based Fall Program
Measurement and Improvement in High Reliability Organizations" OJIN: The Online
Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 5.
DOI: 10.3912/OJIN.Vol18No02Man05
Key words: Falls, measurement, nurse sensitive, High Reliability Organizations
Advancing measurement and improvement around falls prevention in the hospital is
important as falls are a nurse sensitive measure and nurses play a key role in this
component of patient care (AHRQ, 2012; Quigley, Neily, Watson, Strobel, & Wright,
2007; White, 2012). A framework for applying the concepts of high reliability
organizations to falls prevention programs is described including determining the impact
at the patient, unit, and organizational level. This article showcases the components of a
patient safety culture and the integration of these components with fall prevention, role of
nurses, and high reliability.
Falls and Fall Injury in Hospitals
Fall measurements have been identified as important to patient outcomes by several
organizations based on the fact that falls are the most frequently reported adverse patient
event among adults in the inpatient setting (Currie, 2008). Fall measurements have been
identified as important to patient outcomes by several organizations...However, not all
falls can be prevented. Falls can be categorized as anticipated, accidental, and
physiological (Morse, 1997). Regardless of the type of fall, injuries can occur in all types
of falls, and programs are designed to prevent falls as well as fall injuries.
Falls represent a major public health problem around the world. In the hospital setting,
falls continue to be the number one adverse event with approximately 3-20% of inpatients
falling at least once during their hospitalization. Of those, 30 to 51% of falls in hospitals
result in some injury (Oliver, Healey, & Haines, 2010). Of these, 6 to 44% experience
similar types of injury (e.g., fracture, subdural hematomas, or excessive bleeding) that
may lead to death. Adjusted to 2010 dollars, one fall without serious injury costs hospitals
an additional $3,500, while patients with more than 2 falls without serious injury have
increased costs of $16,500. Falls with serious injury are the costliest with additional costs
to hospitals of $27,000 (Wu, Keeler, Rubenstein, Maglione, & Shekelle, 2010). Many
interventions to prevent falls and fall-related injuries have been tested. However, they
require multidisciplinary support for program adoption and reliable implementation for
specific at-risk and vulnerable subpopulations, such as the frail elderly and those at risk
for injury (Oliver et al, 2010; Spoelstra, Given & Given, 2012). The following
organizations are key stakeholders in falls and data prevention.
Center for Medicare and Medicaid Services(CMS) and Hospital Falls Data
Improving the quality of care and patient safety is a priority for government, payers, and
providers, and falls are one example of concern to these health care organizations.In
2008, the Center for Medicare and Medicaid Services identified falls as a Hospital
Acquired Condition. In 2008, the Center for Medicare and Medicaid Services (CMS)
identified falls as a Hospital Acquired Condition (HAC). An HAC is a complication or
comorbidity (CC) or major complication or comorbidity (MCC) that occurs as a
consequence of hospitalization and is high volume and/or high cost, and be reasonably
preventable using evidence-based guidelines (Radey & LaBresh, 2012). CMS has
identified eight HACs from billing data, and falls and trauma including fractures,
dislocations, and intracranial injuries are all categorized as HACs, listed in Table 1. CMS
will no longer cover the cost of care as a consequence of an inpatient fall based on the
presumption that falls are preventable by the organization (CMS, 2009).
The Joint Commission (TJC
Furthermore, TJC (2013) requires accredited hospitals to conduct fall risk assessments for
hospitalized patients to identify patients’ risk for falls so that prevention measures can be
implemented into the plan of care (The Joint Commission, 2013). TJC began to monitor
sentinel events in 1995, and through the end of 2012, there have been 659 fall related
events which resulted in death or permanent loss of function that were voluntarily
reported as a sentinel event. This number reflects voluntary reporting and represents only
a small portion of actual events. The actual number is unknown but is most likely much
greater, attesting to the importance of fall prevention interventions. What is clear is that
patients are still falling in hospitals and experiencing injury (The Joint Commission, n.d.).
The depth and breadth of program evaluation must be expanded; applying the concepts
from high reliability organizations can assist in better results. Dr. Mark Chassin, current
President of TJC, and Dr. Jerod Loeb, executive vice president, conclude that the health
care industry can achieve excellence in safety and quality through three components that
support high reliability – leadership, safety culture, and robust process improvement
(Chassin & Loeb, 2011). Through these processes, care can be made more effective,
efficient, and less vulnerable to failure which may result in patient harm.
National Database for Nursing Quality Indicators (NDNQI) and Falls Data
Most hospitals collect data on falls for internal analysis, and many also participate in
external databases such as the National Database for Nursing Quality Indicators
(NDNQI) as part of their Magnet™ designation quality improvement program (American
Nurses Association, 2010) or part of their general improvement program as this provides
an external benchmark comparison. NDNQI reports provide internal and external
comparison with like-units in like-facilities...quality indicators link nursing care to patient
outcomes.Through benchmark comparison with similar types of nursing units,
organizations are then able to assess their performance and determine opportunities for
improvement. However, fall risk assessment and analysis of fall rates and injury rates
only serves as the foundation for program measurement and evaluation.
As part of patient safety programs, clinicians, administrators, and risk managers
collaborate to set realistic target goals for reducing rates of falls and fall-related injuries.
They review, compare, and analyze epidemiological data that is both population and
setting-specific, using both internal and external data. The American Nurses'
Association's (ANA) National Database of Nursing Quality Indicators® (NDNQI®)
enables comparison of injury fall rates based on severity of injury and other nurse
sensitive indicators for participating acute care organizations (American Nurses
Association, 2004-2006). NDNQI reports provide internal and external comparison with
like-units in like-facilities including bed size, teaching status, Magnet status, and other
parameters.
ANA quality indicators link nursing care to patient outcomes. Patient injury rate, noted to
be most often caused by falls, was promoted as a nurse sensitive indicator, a measure of
quality that links patient outcomes with availability and quality of professional nursing
services (ANA, 1995). ANA has asserted nurses' responsibility to assess patients' risk for
falls and injury; design and implement risk reduction care plans; and evaluate
effectiveness of clinical fall prevention programs. ANA also recommended consistency of
data reporting, measurement and analysis. Because of these efforts, participating NDNQI
hospitals can evaluate the efficacy of their processes tracked by NDNQI, such as the use
of valid and reliable fall risk screening tools. Moreover, standardized post fall analysis
and rates are available to analyze patient safety programs and clinical effectiveness.
Examples of fall-related data specific to care processes and outcomes provided by
NDNQI are listed in Table 1.
National Quality Forum (NQF) and Falls Data
Injury falls are often termed as “never events” by the National Quality Forum (NQF).
These falls are associated with increased morbidity/mortality rates and also impact
reimbursement. As falls are a nurse sensitive measure, nurses play a pivotal role in the
prevention of falls and fall injuries. The NQF developed 28 never events that should
never occur to a patient while being cared for in a healthcare facility. Process and
outcome fall-related measures are listed in Table 2. Additionally, NQF captures data on
death or serious disability associated with a fall as one of those never events. Recently,
the NQF endorsed the ANA’s NDNQI quality measures to improve patient safety in
hospitals - patient fall rate and patient falls with injury (National Quality Forum, 2013).
Agency for Healthcare Research and Quality (AHRQ) and Fall Fracture

...fall prevention programs must include multicomponent interventions to reduce falls,

which are ready for adoption now.The AHRQ provides numerous tools associated with
falls prevention, but it is primarily viewed as a resource for evidence based practice.
Specific to falls, AHRQ has defined a patient safety indicator for measuring the rate of
postoperative hip fractures (Table 1). In their recent publication of 22 safety practices on
falls, the authors note that “attention to multiple risk factors is more effective than an
intervention that targets any single risk factor,” creating a multi-systematic fall prevention
model which is consistent with a systems approach to improving safety and reliability of
care (AHRQ, 2013a). Thus, fall prevention programs must include multicomponent
interventions to reduce falls, which are ready for adoption now (Miake-Lye, Hempel,
Ganz, & Shekelle, 2013).
Table 1 illustrates how falls and injury measures are defined by the organizations
described in this article. A comparison of these major organizations and process and
outcomes data specific to falls and injury rates reveals differences as well as similarities
in measurement.
Table 1. Comparison of Fall and Injury Measures by Organizations
NDNQI NQF “Never CMS Hospital AHRQ Patient TJC
Event” Acquired Safety Indicator
Conditions
(HACs)
Process Process Process Process Process
Fall risk Fall risk None Fall risk
assessment assessment None assessment
*Time since defined by the
last fall risk organization
assessment (TJC
PC.01.02.08)
Outcomes Outcomes Outcomes Outcomes Outcomes
Fall rates Fall rate Falls and Postoperative Data presented
Fall injury rates Fall injury rate trauma,includin hip fracture rate to demonstrate
Fall assessment *Patient death g: (PSI #08) improvement
Repeat fall or serious -Fractures defined by the
rates disability -Dislocations organization
Injury rates of associated with -Intracranial (TJC.PI.03.01.0
moderate and a fall while injuries 1)
higher Injury being cared for (Must have
level in a healthcare occurred in
Percent of facility acute hospital)
patients who
fell

High Reliability Organizations: Current Model

The trend to advance patient safety and quality in health care organizations is based on
implementing the concepts of high reliability organizations (HRO). Experts (Pronovost et
al., 2006; Weick & Sutcliffe, 2007) agree that high reliability organizations are those that
achieve a high degree of safety or reliability despite dangerous or hazardous conditions.
The trend to advance patient safety and quality in health care organizations is based on
implementing the concepts of high reliability organizations.The nuclear and airline
industries are noted as some of the most hazardous industries and have often been cited
for their defect-free or error-free operations for long periods of time. Case studies of the
Three Mile Island nuclear incident, the Challenger and Columbia explosions, the Tenerife
air crash and other events examine how these events occurred and the similarities in these
high risk situations, giving rise to studying and defining reliability in hazardous
organizations. This study of HROs can lead to organizational behaviors that demonstrate
anticipation, resilience, and constant improvement (Weick & Sutcliffe, 2007).
Based on the HRO model, many compare health care organizations as aspiring to emulate
characteristics of other HROs to minimize errors and achieve exceptional performance in
patient safety and quality. There are great opportunities to improve by moving in this
direction. Some studies indicate that core processes in health care are defective 50% of
the time and patients receive only about 55% of the appropriate care when entering the
health care system (McGlynn et al., 2003; Resar, 2006).
Efforts to lead this improvement movement come from a variety of sources such as those
noted earlier (e.g., CMS HACs for the Hospital Inpatient Quality Reporting Program,
TJC Center for Transforming Healthcare with Targeted Solutions Tools, AHRQ, NDNQI
measurement system, and NQF “never events”). Each of these organizations and/or
initiatives promotes error or defect free health care through interventions and measures
that support this goal. There is clearly a unified goal across organizations to support a
culture for patient safety and quality of care through continuous improvement and
systems, which must also include measurement systems.
HRO Core Characteristics
The core characteristics of HRO have been well documented in the literature from the
work of Weick and Sutcliffe (2001; 2007) on creating a culture and processes that reduce
system failures and respond effectively when failures/errors do occur. These
characteristics include:
 Sensitivity to operations - a constant awareness by leaders and staff of the state of
systems and processes that affect patient care so that risks can be noted and
prevented.
 Reluctance to simplify - the ability to streamline processes but not oversimplify
explanations for adverse events in order to understand the true reasons why patients
are placed at risk.
 Preoccupation with failure - a focus to thoroughly examine root causes for a
problem; make improvements; and view near misses as evidence of systems that
should be improved to decrease potential harm to patients and not as proof that the
system has effective safeguards.
 Deference to expertise - leaders listen to and respond to others’ insights, including
direct care clinicians, patients, and family members; leaders listen to the insights of
staff who know how processes work and the risks patients really face. Weick and
Sutcliffe (2007) called this “knowledge before hierarchy.”
 Resilience - leaders and staff are trained and prepared in how to respond when
system failures do occur.
The focus of a HRO is safe reliable performance.The focus of a HRO is safe reliable
performance. By embedding the core characteristics into the fabric of the organization,
leaders build expectations into the daily organizational roles, routines, and strategies.
These expectations create order and predictability around processes and practices that
allow members of the organization to manage unexpected events through “mindfulness.”
Mindfulness is greater than situational awareness; it is a greater awareness of
discriminatory detail that provides organizations with the “big picture.” It helps identify
early warning signs that some unexpected event is unfolding and action needs to be taken.
This mindfulness increases alertness and readiness to potential problem areas in the here
and now. HRO principles steer people toward mindful practices that encourage timely
response toward unexpected events. If an event does occur then the person is mentally
ready to work on recovery and minimize disruption from the event (Weick & Sutcliffe,
2007).
Weick and Sutcliffe (2001; 2007) described three types of unexpected events that require
mindfulness to ensure safe reliable performance:
1 When an event that was expected to happen fails to occur
2 When an event that was not expected to happen does happen
3 When an event that was simply un-thought of happens.
HRO practices can be applied to a falls prevention program, including how to deal with
unexpected events. For example in HROs, every event and near miss is reviewed with
performance evaluated. In a falls prevention program, each fall is reviewed; near falls are
rarely reviewed. In HROs, multiple checks in multiple ways are completed. In a falls
prevention program, there are multiple fall interventions and multiple methods of
implementation such as purposeful rounds, environmental rounds, and interdisciplinary
care planning. In HROs, continuous communication is the norm. In a falls prevention
program, frequent communication occurs such as hand-off communication about fall risk
factors and related interventions; signage to communicate patients who are known fallers
and those at risk for serious to moderate injury; pre-shift and post fall communication
huddles; and interdepartmental handoff detailing fall; and injury risk factors and
protective interventions.
HRO practices can be applied to a falls prevention program...In HROs, the importance of
routines and predictable behaviors is emphasized. In a falls prevention program, routines
for fall risk assessment and reassessment, as well as routine interventions, are
standardized into practice. In HROs, it is a necessity to improvise or bounce back after an
event (Weick & Sutcliffe, 2007). In a falls prevention program, one must quickly assess
the patient post fall in order to effect immediate treatment or a change in interventions
needed to prevent a reoccurrence.
Riley (2009) described four tools that support the design and implementation of processes
for high reliability: process maps, control charts, a model for improvement, and health
care bundles. All four of these tools can be applied in fall and injury prevention program
evaluation. Process maps can be used to describe the steps in assessment, reassessment,
interventions, and evaluation of falls. They can also be used to track timelines for
implementation of interventions from idea generation through implementation and
evaluation. Control charts can be used to analyze fall rates overall; type of fall; repeat
falls; fall injury and level of severity; number of days between preventable falls; and
serious injury; within defined upper and lower control limits over time to determine if the
process is stable. Several models of improvement can be found in the literature to support
improving the process to reduce fall and injury rates. The most common model is the
Plan-Do-Study-Act model or the Institute for Healthcare Improvement (IHI) model for
improvement (Langley, Nolan, Nolan, Norman, & Provost, 2009). Lastly, a fall bundle of
interventions can be applied based on risk, population, and setting.
Components of a Safe Culture
...a HRO staff adopts a style of functioning that promotes continuous learning.The
concepts of a HRO cannot be fully separated from the components of a safe culture.
There are different dimensions or ways to perceive how different factors contribute to
patient safety and quality within an organization. For example, a HRO staff adopts a style
of functioning that promotes continuous learning. When these behaviors have not been
adopted, it is more difficult to create reliable performance and detecting failures is more
likely to not occur and leads to more significant adverse events. When the culture has not
embraced the HRO concepts and experienced a failure, the following have been
frequently found (Weick & Sutcliffe, 2007):
 Recent changes in supervision
 Issues delegated without follow-up
 Lack of a questioning attitude
 Missed steps in a procedure
 People not on the same page
 Staff spread thin
 Distraction from schedule pressure
The AHRQ (2013a) recent publication of 22 safety practices, in which falls prevention
was presented, also identified the seven elements listed below that contributed to success
in a falls prevention program. These elements have similarities to other aspects of a safe
culture.
 Leadership support
 Engagement of front line clinical staff
 Multidisciplinary committees
 Pilot test of interventions
 Informational technology system for data collection and management
 Changing the prevailing attitude that “falls are inevitable”
 Adequate time for education and training
Analysis of errors identifies many similar factors that contribute to error-prone situations
(Weick & Sutcliffe, 2001). In reviewing those components that most strongly support a
culture of patient safety, several emerge including leadership, teamwork, evidence based
practices, and measurement and reporting systems (Byers & White, 2004; IOM, 1999;
2001b; Sherwood & Barnsteiner, 2012). While these are not the only factors that support
a safe culture, these four factors with support for a strong impact will be discussed in this
section.
Leadership
The essential components of a safe culture begin with leadership. Key leaders are aware
that the health care environment is one of risk and they seek to reduce this risk by
aligning the vision, mission, and fiscal and human resources with frontline direct care
(Beaudin & Pelletier, 2012; IOM, 1999; Sherwood & Barnsteiner, 2012). Nurse leaders
recognize how strong nursing processes, interventions, and evaluations of care through
measurement systems support a patient safe culture and reduce risk and harm to patients.
An example of reducing risk and harm to patients is a program designed to prevent falls
and injuries from falls. Nurses hold key leadership positions and clinical practice roles,
vital to shaping high performance fall program outcomes at the organizational, unit, and
patient levels through leading/coordinating multi-component individualized care planning
with interdisciplinary teams. The need for leadership is noted as the first step in almost
any improvement initiative in order to garner resources and support for implementation
across the organization (White, 2011).
Team Work
Safe culture is further strengthened by strong interdisciplinary teams, which includes
collaboration and cooperation among leaders, nursing staff, and staff from other
disciplines. Safe culture is further strengthened by strong interdisciplinary teams...Teams
should apply evidence-based practices to improve standardization and reduce unwanted
variation in processes. Effective teams are manifested by open communication whereby
leaders facilitate each member' ability to speak up on behalf of a patient, and in which
teams have a clear vision and purpose of the roles of each member. Teams need regular
feedback and should be capable of correcting behaviors that do not promote patient
safety. Members in a strong safety culture demonstrate clear communication among all
staff and this communication is frequent. Frequent, open communication engenders trust
among members, and there is ongoing learning in which healthcare system leaders gain
wisdom from mistakes and seek to continually improve processes and performance. Safe
culture is one that views errors as system failures rather than individual failures (Beaudin
& Pelletier, 2012; Byers & White, 2004; IOM, 1999; Riley, 2008). The entire focus is
patient-centered; safety and quality of care in the health care system is centered on
patients and families.
Evidence –Based Practice
The role of nursing in using HRO concepts to support safe patient care in fall prevention
and fall injury prevention includes a strategy for the implementation of evidence-based
practice (EBP). EBP will promote standardization, reduce variation, and strengthen the
focus on preoccupation with failure. In this example, the failure would be a fall, and even
more serious is a fall with injury.
Evidence regarding major factors that reduce errors in health care systems targets
effective communication and trans-disciplinary work. Evidence for the most successful
fall prevention programs suggests multifactorial and interdisciplinary components (Oliver
et al., 2010). In HROs, a set of barriers to protect the patient from harm is a hallmark
feature. In a multifactorial falls prevention program, there will be many systematic
barriers established to reduce the risk of a fall and injury. Evidence based interventions
will improve standardization in processes and decrease variation (Oliver et al, 2010;
Miake-Lye et al., 2013; Radly & LaBresh, 2012; Sepolstra et al., 2012). This is seen in
fall prevention programs in which fall bundles to prevent falls and injuries allow
standardized application of evidence such as risk assessment using a valid and reliable
tool. Improved systems design includes use of checklists, decreasing interruptions,
preventing fatigue, avoiding task saturation, reducing clinician stress, and improving
environmental conditions. These design elements can be found in fall prevention
programs such as lists of possible fall prevention interventions and fall injury
interventions. Modifications and improvements to environmental conditions that reduce
the risk of falls may include lighting; flooring to absorb impact of a fall; handrails to
assist with ambulation; elimination of trip hazards with raised thresholds, sloping ledges,
and curbs; and marking trip hazards to increase their visibility (AHRQ, 2013; NCPS,
2004).
In 2013, AHRQ published 22 safe practices, one of which targeted preventing in-facility
falls (Ganz, Huang, Saliba, & Shier 2013). Because most fall prevention programs are
multifactorial, the best the authors could do in identifying and reviewing the evidence
was to describe interventions that have been evaluated, including the following:
 Post fall review
 Patient education
 Staff education
 Footwear advice
  Scheduled and supervised toileting
 Medication review
The AHRQ toolkit for falls provides resources and tools that enable hospitals to monitor
and evaluate structures, processes and outcomes (AHRQ, 2013). This toolkit draws on a
systematic review of current literature and evidence as well as expert opinion. Where the
evidence exists it is cited, but where the evidence is not clear the use of experts and
clinical experience are presented. Additionally, the Veterans Administration National
Center for Patient Safety (VA NCPS) Falls Toolkit supports evidence based practice for
falls prevention (NCPS, 2004).
Measurement and Reporting Systems
A balancing measure might be the number and cost of sitters associated with the program
or staff injury associated with trying to support patients in an assisted fall.Measurement
systems support a patient safety culture (IOM, 1999; IOM, 2001b). Measurement systems
include several types of measures. Donabedian (2005) is known for his structure, process,
and outcome measures. Additionally, there are balancing measures. These measures
provide a method of assessing the impact of a process not only on the desired measure of
interest, but also on other areas which may be positive or negative. In Table 2, an
example of each type of measure associated with a fall and injury prevention program is
presented. For example, the fall prevention program could include use of sitters to
monitor patients who have fallen to prevent repeat falls. The primary outcome measure is
fall rate per 1000 patient days. A balancing measure might be the number and cost of
sitters associated with the program or staff injury associated with trying to support
patients in an assisted fall.
Injury analysis by severity levels enables clinical and administrative staff to profile both
vulnerability of patients and effectiveness of patient safety programs. For example, if
70% of elderly patients who sustain lateral falls incur hip fractures, one might suspect a
large prevalence of osteoporosis. If one unit exceeds other units on their monthly fall
rates and has higher injury rates, one would target that unit for evaluation and
intervention. In addition to tracking injury and injury severity rates, another performance
indicator is the number of days between major injuries. Increases in the length of time
between major injuries are another indicator of the effectiveness of fall reduction
programs.
Table 2 illustrates Donabedian’s framework for measurement including structure, process,
outcome, and balancing measures. Examples of these measures in a fall prevention
program are presented as to the type of measure. Nurses in a HRO will continue to
examine their processes and focus on improvement to reduce risk of falls within their
healthcare setting. As experts on fall and fall injury prevention, nurses are critical to lead
teams that develop, implement, and evaluate programs.
Table 2. Types of Measures and Fall and Injury Prevention Program Examples
Measures Fall Prevention Program Examples
Structure Measures Nurse staffing on unit (Nurse to patient ratio)
Number and percent of professional nurses (RNs) and
other nursing staff (e.g., sitters)
Interdisciplinary members on falls team
Injury reduction products
Fall present on admission (POA)

Process Measures
Outcome Measures
Balancing Measures
Fall Injury POA
Post fall huddle
Fall risk screening specific to anticipated physiological fall
Fall risk assessment/ reassessment (Number of patients
identified as high, moderate, low risk to fall)
Fall injury risk/history assessment (Number of patients
identified as high, moderate, low risk to incur a fall injury)
Fall prevention interventions (e.g. no slip socks, assistive
devices, handrails, low bed, chair and bed exit alarms)
Fall injury prevention interventions (e.g. hip pads, floor
mats)
Completion of hourly rounds
Assisted falls (unassisted fall)
Post fall assessment
Fall rate per 1000 patient days (by type of fall)
Fall injury rate per 1000 patient days (by severity)
Percent of fall injuries that are major injuries
Days between major fall injury
Repeat fall by type of fall
Repeat fall by patient
Reduction in modifiable fall risk factors
Use of sitters for fall prevention (e.g., number, cost)
Use of restraints to prevent patient from getting out of bed
and falling
Additional staff required for hourly rounds
Staff injury (associated with assisted fall)

Determining the Impact of Safe Care: Nurses’ Role at Multiple Organizational Levels
Nurses play a key role in ensuring quality and patient safety in health care. Nurses are
most likely to spend the greatest amount of time with patients and are in a strong position
to monitor and mitigate risks and improve patient outcomes. While nurses may impact
numerous clinical processes and outcomes, the example of falls and injury prevention as
nurse sensitive measures will be reviewed as an exemplar framework for demonstrating
safe, quality care at the organization, unit, and patient level. Table 3 details critical
contributions of nurses to program effectiveness. This framework enables nurses to
determine the impact of safe care at multiple levels. Table 3 describes the role of nurses
within hospital organizations to demonstrate competency and functions that support
HROs. Sherwood and Barnsteiner (2012) summarize the Robert Wood Johnson
Foundation Quality and Safety Education for Nurses (QSEN) framework that was
developed to transform nursing education to integrate competencies specifically for
quality and safety. This framework will begin to shape prelicensure nursing skills to
ensure the future generations of nurses are better able to support HROs. Elements in
Table 3 support the current workforce changes important to HROs.
In addition, Riley (2008) made recommendations for nurse leaders to ensure that high
reliability is embedded as a core characteristic of the organization. These
recommendations were translated into a practical application for a falls prevention
program in Table 4.
Table 3. High Reliability Organizations (HROs) and Role of Nurses in Fall and Injury
Prevention Program
Key Elements of HRO Role of Nurses
Organizational Level Critical Contributions
Team Training/Competency Validation Training of nurses on falls prevention
program, EBP on interventions, rounding
methods and elements
Competency assessment in EBP and
nursing interventions and practices to
prevent falls and injuries
Design Care Processes to reduce risk and Fall prevention and fall injury prevention
harm processes integrated into nursing process
(assessment, reassessment, planning,
tailored interventions, patient education,
evaluation of intervention effectiveness)
Organization wide program with
customization for selected populations (e.g.
pediatrics, geriatrics) and settings (e.g.
acute care, long term care, home care)
Surveillance via standardized safety rounds
(hourly)
Core Processes Understood and Measured Measurement system for a fall prevention
program (see Table 2)
Structure Measures
Process Measures
Outcome Measures
Balancing Measures
Error Proof the Organization Fall injury prevention program
Implement multiple tools/methods to
prevent this "error" or defect
Process Standardization Fall bundles implementation, measurement,
and evaluation
Nurses in all roles and at all levels of the organization have a shared and integrated
responsibility to apply concepts of HROs to patient safety programs, such as fall and
injury prevention. The HRO framework is applied to nursing process specific to nurses in
administrative and direct care roles in Table 4. While the literature continues to discuss
how the concepts of HROs can be applied in health care organizations, less is specifically
discussed within nursing in order to integrate the concepts into practice at the patient,
unit, and organization level. Table 4 begins to compare and contrast the roles of a nurse
leader at the organizational level, such as Chief Nurse or Vice President of Patient Care
Services, in setting the cultural tone, providing the resources, and setting expectations
about measures. This role has been specifically addressed by Kerfoot (2007) and Riley
(2008) for nurse leaders.
More broadly, the Institute of Medicine (IOM) has highlighted the importance of patient
safety (1999; 2001; 2004) and recently focused on the role of nurses in ensuring patient
safety in health care (IOM, 2004). If nurse leaders create the culture, nurse managers at
the unit level sustain this culture through consistency and reliability across units. This
includes the application of evidence-based practices across units, such as fall prevention
interventions,and the measurement system for a falls prevention program that
standardizes definitions, interventions, tools, and reports. Kerfoot (2007) notes that
through a shared leadership structure, nurse managers are the “powerhouse” to get things
done. “If full compliance with this procedure on all units at all times is lacking, high-
reliability practices and flawless execution are impossible” (Kerfoot, 2007, p.274). At the
nurse-patient interface, the strongest defensive barriers to protect the patient from injury
(such as falls and fall injuries) come from the system of layers of protection (Riley,
2008), which are well described in Reaon’s (1990) work on systems and errors and the
concept of the “Swiss Cheese”.
Table 4. Translating HRO Concepts to Nursing Practice
HRO Concept Organization Level Unit Level Patient Level
(macrosystem) (microsystem)
Level Nurse Leader Nurse Manager Nurse at Bedside
Culture Create a safe culture Translate the Report falls and
for reporting errors culture for injuries (without fear)
without blame reporting and Communicate patient-
Support culture of error analysis to reported and nurse-
open the unit level assessed risk factors
communication Communicate and
Support just culture determine
in which systems interventions post fall
and process issues
are understood as
primary causes of
errors vs.
individuals
Leadership Support staff to Support unit and Incorporate program/
attend training interdisciplinary interventions into daily
Support a shared collaboration and existing workflow
leadership structure use of EBP Identify current EBP
(e.g. shared on falls prevention
governance) in Involve patient and
which best practices family in education
are shared, and fall and shared decision
prevention program making re-
design includes interventions
front line nurses and
clinical experts
Resources Provide resources Apply resources Implement specific
for fall prevention on the unit based tools, equipment and
program (e.g. on type of unit time into practice for
assistive devices, and patient falls prevention
 mats, hip protectors, population and Conduct safety rounds
exit alarms, patient needs
environmental Design and
adjustments) implement
Provide appropriate staffing patterns
nursing staff to to support the
implement falls program
prevention program
Allow time for
safety rounds
Team Support nurse Collaborate with Be a unit based
manager/leader nurse managers of champion for falls
collaboration and other units and prevention
consistency across with managers of Participate on team
nursing units for other disciplines huddles and/or
standardized reliable to create committees in which
processes interdisciplinary fall prevention
team approach to program is addressed
falls prevention or in huddles post fall
Fall and Injury Expand data Implement fall Collect daily fall and
analysis measures to and injury injury data for
include: protocols specific reporting
-Fall rate to patients with
-Fall rate by type of history of falls
fall and type of injury
-Injury rate Fall rounds to
-Injury rate by individualized
severity patient care plans
-Percent of patients Purposeful
who fell rounding (linked
-Percent of patients to type of fall)
at high risk for fall Post fall huddles
-Percent of patients Collection of data
who fell more than and reporting of
once system measures
-Percent of patients
at risk for moderate
to serious injury
-Percent of patients
with fall POA
-Percent of patients
with fall Injury
history POA
Establish system
level measures and
measurement
 systems
Safety of Care Measure:
-Percent of patients
at high risk for falls
that did not fall
-Percent of patients
with fall injury
history POA who
did not fall
-Percent of patients
with fall and injury
history POA who
did not fall
Support for
consistent reliable
results

Discussion
In 2007, TJC provided guidance to hospital leadership to evaluate fall prevention
programs. Knowledge of fall prevention program deployment and evaluation using a high
reliability model and statistical analysis can help nurses design and test effectiveness of
fall and injury prevention programs.This fall program evaluation included analysis of
structures (e.g., nurse staffing, nursing skill mix, and interdisciplinary participation) and
processes (e.g., timeliness of assessment, implementation of interventions, involvement
of patients and caregivers) of an organization’s falls prevention programs, which then
enables analysis of outcomes – falls, injury from falls, and cost of falls. All organizations,
TJC, NDNQI, NQF, and AHRQ, emphasize nurses’ contribution to patient safety by
assessing fall risk and designing patient-specific fall prevention interventions that reduce
risk and prevent falls and fall-related injury.
Nurses’ leadership and clinical judgment is critical and affirmed (IOM 2003). However,
nurse organizational leaders must expand program evaluation beyond the point of care at
the patient level, to include key attributes at unit and organizational levels. Knowledge of
fall prevention program deployment and evaluation using a high reliability model and
statistical analysis can help nurses design and test effectiveness of fall and injury
prevention programs (Quigley et al., 2007). Organization, unit, and point of care
infrastructure, capacity, and interventions can be tracked and evaluated to identify best
system practices.
For example, if a hospital determines that 30% of falls resulted in injury, they must
examine environmental hazards that contribute to injury, organizational infrastructure,
and capacity to protect patients from injury. Hospital leaders must examine organizational
and unit-level infrastructure and capacity to reduce trauma when a patient falls. They
must also examine strategies to eliminate sharp edges, objects able to be struck as a
patient falls from one level to another, and blunt force trauma from unprotected flooring
in rooms, bathrooms, and showers. This rate of injury is higher than published literature;
the rate of those who fall with some injury is 30 to 51% (Oliver et al., 2010).
In contrast, if a hospital determines that 5% of the falls with injury are moderate to
serious, the hospital must examine its fall injury reduction program, focusing on risk for
moderate to serious injury upon patient admission. The hospital should implement
multifactorial interventions to protect vulnerable patients with strategies advised by the
Department of Veterans Affairs and the Institute for Healthcare Improvement TCAB
(Boushon et al., 2012; Quigley et al., 2010). Risk for serious injury is separate from risk
for fall, and is based on known clinical conditions, such as osteoporosis and
anticoagulation. Interventions to protect from injury are separate from the interventions to
reduce fall risk factors.
Meaningful use of program evaluation that includes in-depth data as core data, enhanced
by additional data analysis, will help nurses and hospital staff evaluate the impact of
interventions. While these examples are hospital-level, this expanded analysis could
occur at the unit level and be compared across units or based on specific populations.
Hospitals can decide on the depth and breadth of program evaluation as a HRO.
To be a high reliability organization, hospitals must analyze falls by type of fall and link
interventions to type of fall at all levels: organization, unit, and patient care, targeting
risks for physical injury in combination with fall prevention.Once systems are developed
for fall rate tracking and internal comparison, organizations can both identify trends and
compare rates to those from national databases. Fall rates should compare with similar
populations. For example, fall rates for acute care units should be compared with those
for other acute care units, those for an organization's dementia populations with similar
populations. Additionally, fall rates should be analyzed by type of fall, defining
preventable from unpreventable falls. Still, this aggregated data analysis is insufficient to
evaluate interventions being implemented per level. Interventions to prevent accidental
falls require infrastructure and capacity at the organization and unit levels in order to be
implemented at the point of care. This same assertion exists for reduction of anticipated
physiological falls.
Organizations must analyze effectiveness of fall and injury prevention programs that are
unit-specific and population-based. The recommendations suggest that clinical,
administrative, and risk management staff conduct in-depth data analysis and provide
unit-specific feedback to staff regarding fall rates and fall related injury rates.
Protecting patients from falls and fall-related injuries requires shared responsibility. Thus,
we propose a population-based model that includes both fall prevention and injury
protection (Figure 1). This model could potentially mobilize changes on a large scale,
produce a normative effect, and achieve a more permanent diffusion process, as
suggested by McClure et al. (2009). The proposed model is specific for hospitals (and
nursing home residents) and includes fall prevention and injury protection interventions
at the organizational, unit, and patient level (illustrated in Figure 2).
Figure 1. Model for Fall Prevention and Injury Protection
Figure 2. Model for Fall Program Comparison [see full size pdf]

At this time, no hospital-based study has examined the effectiveness of both fall
prevention and protection from injury nor estimated the relative weight of intervention
components to outcomes (Oliver et al., 2010; Quigley et al., 2010). To be a high
reliability organization, hospitals must analyze falls by type of fall and link interventions
to type of fall at all levels: organization, unit, and patient care, targeting risks for physical
injury in combination with fall prevention. The exact combination of interventions for
specific populations must build on the assumption that all inpatients are at risk for falls,
repeat falls, injury, and unfortunately death from a fall, in order to provide a protective
approach and demonstrate high performing organizations
Conclusion
Increasing regulatory and reimbursement changes challenge the health care industry to
reduce hospital adverse conditions.Extensive literature documents the burden of falls to
individuals, healthcare organizations, and society. Falls are categorized as an adverse
event and usually further classified as accidental. Increasing regulatory and
reimbursement changes challenge the health care industry to reduce hospital adverse
conditions. Yet the measurement systems utilized for performance remains at the
aggregate level, not affording precise evaluation of program changes and measurement.
We assert that measurement must change by setting up program evaluation that examines
organizational, unit, and patient level data. Our proposed model for program evaluation,
applied in this article to a fall prevention program, enables robust evaluation and better
depicts a high reliability organization (HRO). This model could be applied to any hospital
adverse condition. We assert that a changed model such as the one described here would
better support identification of best performance and showcase safe hospitals.
Disclaimer: This material is based upon work supported by the Department of Veterans
Affairs. The views expressed in this article are those of the authors and do not necessarily
represent the views of the Department of Veterans Affairs.
Authors
Patricia A. Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP
E-mail: Patricia.Quigley@va.gov
Dr. Patricia Quigley, PhD, ARNP, CRRN, FAAN, FAANP, Associate Director, VISN 8
Patient Safety Center of Inquiry, is both a Clinical Nurse Specialist and a Nurse
Practitioner in rehabilitation. Her contributions to patient safety, nursing, and
rehabilitation are evident at a national level, with emphasis on clinical practice
innovations designed to promote elders’ independence and safety. As Associate Chief,
Nursing Service for Research and nurse researcher, she is responsible for advancing
nursing and interdisciplinary knowledge, skills, and capacity for the conduct of research
and research translation. She leads an interdisciplinary clinical team in the development
of evidence-based assessment tools and clinical guidelines related to assessing veterans’
risk for falls and fall-related injuries across multiple medical centers. Additionally, she
provides on going consultation to the nursing staff, quality management, and patient
safety coordinators for management of complex patients at risk for falls.
Susan V. White, PhD, RN, CPHQ, FNAHQ, NEA-BC
E-mail: Susan.White4@va.gov
Dr. Susan V. White, PhD, RN, CPHQ, FNAHQ, NEA-BC, is the Chief of Quality
Management at the Orlando VA Medical Center. Her current areas of responsibility
include quality management, performance improvement, accreditation, patient safety, risk
management, infection control, and credentialing and privileging. She has previously
served as Magnet coordinator leading an organization to renewal of its designation. She
has an extensive career in the healthcare field, including nursing administration,
management, and clinical roles. Her work through various positions has included
accreditation related activities, resources on quality initiatives, initiatives on clinical
performance improvement and patient perception, educational programs, and patient
safety. She is a member of multiple professional organizations and has served on several
boards in the state including the Florida Center for Nursing.
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Article published May 31, 2013