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Background: The purpose of this self-assessment tool is to identify what processes of care your hospital has in place and what areas need improvement.
Reference: Adapted from AHRQ publication on the Falls Management Program for nursing homes. www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm.
How to use this tool: This tool should be filled out by the Implementation Team leader. Use your hospital's policies, procedures, and general practices to answer the questions.
The results from this self-assessment can help you identify which areas need improvement and develop a plan.
Current Fall Prevention Policies and Practices
| A. Culture, Organizational Commitment, and Team Skills | Yes | No | Comments |
|---|---|---|---|
| 1. Updated policies and procedures for a comprehensive fall prevention program? | |||
| 2. Appointed falls team leader and resource person for staff? | |||
| 3. Selection of staff members for interdisciplinary falls team? | |||
| 4. Monthly falls team meeting using ground rules, leader, timekeeper, and recorder? | |||
| 5. High-level managers attend team meetings periodically and monitor falls data at least quarterly? | |||
| 6. No blame/no shame environment with honest investigation and reporting by staff? | |||
| 7. Celebration of success stories and rewards for caregivers who reduce falls? | |||
| 8. Adequate staffing for team leader to spend 8 hours/week and team to meet for 60 minutes/month? | |||
| 9. Funds for adaptive equipment and environmental modifications? | |||
| 10. Employee orientation materials emphasize importance of and hospital commitment to patient safety? |
| B. Data Collection and Analysis | Yes | No | Comments | |
|---|---|---|---|---|
| 1. Accurate completion of fall incident report form by all staff? | ||||
| 2. Monthly falls analysis by: | Location and time of fall | |||
| Shift and day of week | ||||
| Type of injury | ||||
| 3. Monthly falls analysis computed as falls/1,000 patient-days? | ||||
| 4. Falls data reported to hospital management every quarter? | ||||
| 5. Feedback about falls data given to direct care staff each month? | ||||
| 6. Falls data trended over 6 months or more? | ||||
| C. Staff Training and Information for Patients and Families | Yes | No | Comments |
|---|---|---|---|
| 1. Education on fall prevention during new employee orientation and training? | |||
| 2. Annual inservice training on fall prevention for all staff? | |||
3. Staff education materials, including:
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4. All nurses trained in a fall response system that includes:
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| 5. Information for families and patients on fall risk reduction? | |||
| 6. Medical staff given information about the program and their role? |
| D. Environment and Equipment Safety | Yes | No | Comments |
|---|---|---|---|
1. Regular inspection of all resident rooms and bathrooms for safety problems, including:
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| 2. All staff trained to inspect and report environmental and equipment safety problems? | |||
| 3. Repair of reported safety problems in a timely manner by maintenance staff? | |||
| 4. Inspection and repair of all wheelchairs, canes, and walkers every 6 months? | |||
| 5. Communications and inspections documented for ongoing monitoring and accountability? |
