Preventing Falls in Hospitals

Being ready for change is a necessary, but not sufficient, prerequisite to changing your organization's approach to fall prevention. Even when a health care organization is armed with the best evidence-based information, willing staff members, and good intentions, the implementation of new clinical and operational practices still requires additional careful organizational planning. Once you have established organizational readiness, the next practice change step is completing a thoughtful assessment of your organization's current practices and knowledge about fall prevention.

Your timeline should balance the need to act systematically and thoughtfully with the need to move quickly enough to maintain momentum by demonstrating progress. This section is designed to help you manage change at the organizational level. We will discuss managing change at the unit level in section 4 and sustaining change in section 6.

In section 1.4, you identified members of the organization who would be willing to take ownership of the improvement effort. As mentioned, we recommend that some or all of those members serve on an Implementation Team to oversee the improvement effort and manage the changes required. To maximize the possibility of successful implementation of the fall prevention initiative, you need to consider the following questions:

• How can you set up the Implementation Team for success?
  • Who should serve on the Implementation Team?
  • How can you help the Implementation Team get started on its work?
  • How does the Implementation Team work with other teams involved in fall prevention?
• What needs to change and how do you need to redesign it?
  • How do you start the work of redesign?
  • What is the current state of fall prevention practice?
  • What is the current state of staff knowledge about fall prevention?
• How should goals and plans for change be developed?
  • What goals should you set?
  • How do you develop your plan for change?
• How do you bring staff into the process?
  • How do you get staff engaged and excited about fall prevention?
  • How can you help staff learn new practices?

Managing Change: Locally Relevant Considerations In trying to manage change at the organizational level, your hospital may experience some of these challenges: The need for an effective fall prevention program, an interdisciplinary approach, and shared ownership and accountability not penetrating through all levels of staff. Issues with staffing and culture: high turnover rates, inertia, and too many initiatives competing for staff attention. Difficulty establishing interdisciplinary teams: Many hospitals have nurse-driven fall prevention committees and are transitioning to interdisciplinary teams. Fall prevention roles need to be better defined across disciplines, and some disciplines have not bought into the need to play a proactive role in fall prevention. These types of challenges are addressed in this section.

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2.1. How can you set up the Implementation Team for success?

The center of successful improvement efforts in fall prevention tends to be an interdisciplinary Implementation Team that has:

• A strong link to hospital leadership.
• Members with the necessary expertise.
• A clearly defined aim (e.g., develop a program to reduce fall incidence by 15% in our hospital in the next year).
• Access to the resources needed to accomplish the aim.

If you already have a hospital fall prevention committee, the committee can become your Implementation Team. This team should include stakeholders who represent the broad range of organizational members with potential roles in fall prevention.

Trying to find one person who can do all these things, instead of a team, is both difficult and risky. Fall prevention is a process that cuts across many different areas of hospital operations and thus requires input from all those areas. In addition, forming a team ensures that efforts will continue even if one or more members move to other activities.

The Implementation Team generally assumes overall responsibility for the design and evaluation of a large-scale change in clinical practices, working with and through other teams throughout the facility. The relationships among these teams will be addressed in later sections.

This interdisciplinary team will have responsibility for overseeing the fall prevention program in your organization, making key design decisions, working with unit-level teams to carry out improvement activities, and monitoring progress. Thus, the implementation team will need some members with clinical expertise and experience.

Successful teams have capable leaders who help define roles and responsibilities and keep the team accountable for achieving its objectives. You will face a number of decisions in setting up the team to lead the fall prevention program. In section 1, we discussed the process of choosing someone to spearhead your fall prevention program, so that person should be identified and involved in the discussion of these questions. Decisions that need to be made before convening the team include:

• How do we determine members of the Implementation Team?
• How can we help the Implementation Team get started on its work?

2.1.1. Who should serve on the Implementation Team?

The most effective teams for overseeing a change project such as this one have several characteristics:

• An interdisciplinary team, including members from many areas with the necessary expertise to address the problem. Senior leadership support is a prerequisite for system change, but change itself comes most effectively from the ground up. Change happens as teams that include frontline health care workers actively engage in high-priority problem solving, such as redesigning processes of care. Including bedside staff as members will be key to tapping their practical knowledge and engaging them in the change process. Tool 2A ("Interdisciplinary Team") provides a list of potential team members.
• Strong link to leadership. While some organizations have found that the only way to have adequate senior leadership support for an initiative is to include a senior leader on the team, this may not be feasible or appropriate in every case. As an alternative, consider asking senior leadership to designate a member of the top management team as the champion for the fall prevention program. The team's leader should stay in frequent contact with the senior leader champion and can approach that person when the team encounters obstacles or needs access to senior leadership.
• Link to quality improvement expertise.The Implementation Team will be strengthened by having a member with expertise in systematic process improvement methods and in team facilitation from the quality improvement or performance improvement department. If your organization does not have a separate department with these functions, consider using informal channels to identify a person with these skills to recruit to the team. In some organizations, a member with improvement expertise successfully coleads the Implementation Team with a clinical colleague.
• Members who influence the areas that will need to be involved in fall prevention. Sometimes it is not possible to anticipate every area that needs to be involved. It is always possible to add team members later, but new members will need to be oriented to the team's history and process.

You may find a checklist useful in considering potential team membership. Your list can include the position/discipline, possible team members, and area of expertise.

	The team member checklist can be found in Tools and Resources (Tool 2A, "Interdisciplinary Team").
	This Institute for Healthcare Improvement Web site ("Science of Improvement: Forming the Team") provides both general principles for team composition and several examples of different clinical improvement teams and their membership: www.ihi.org/knowledge/Pages/HowtoImprove/ ScienceofImprovementFormingtheTeam.aspx ).
	Implementation Team Composition Hospitals often find it very important that their team be truly interdisciplinary. This composition ensures that as a group, they can understand fall prevention from multiple perspectives and integrate hands-on knowledge and expertise into their prevention efforts. Hospitals find the Interdisciplinary Team tool ( Tool 2A) useful to identify additional Implementation Team members to invite to team meetings. For example, hospitals use the tool to involve additional individuals with such roles as risk manager, physical rehabilitation director, and pharmacist. Hospitals report it is important to include senior leadership to help secure resources and connect the team to other helpful staff and departments. Because hospitals are organized differently, the exact titles and roles of the people you invite to the team may be different from these examples.

2.1.2. How can you help the Implementation Team start its work?

Changing routine processes and procedures to alter the ways people conduct their everyday work is a major challenge. Successful implementation teams—teams that achieve their goals and sustain improved performance—pay attention to the development of routines that make the new practices for fall prevention better than existing practices. They identify and implement new practices that are easier, more reproducible (not reliant on memory), and more efficient than old practices.

The Implementation Team itself needs structure to achieve its objectives. Items to settle on early include:

• How often to meet (e.g., monthly).
• Ground rules or guidelines for how to manage meeting time and for how to communicate, both internally and externally.
• Timeline for the team's work so that there is a shared understanding of the level of urgency and priority this effort requires.

Consider:

• How will the team do its work? This question refers both to the resources the team may need (information, material) and to its methods of working. How will the team track issues raised, explored, and addressed? How will the team assess current knowledge and practice? How will the team use that information to redesign practice?
• What is the team's agenda? This related question emphasizes the importance of giving the team a clear charge and scope for its work. Can leadership provide team members with a clear understanding of the short- and long-term goals and timeframes for the implementation of improved fall prevention practices? For example, leadership may provide the team with a written charge that specifies target dates and improvement goals.

Establish the scope of the Implementation Team's charge. Develop a clear statement of the team's charge. Ensure that senior leadership agrees with this charge. Make sure that the team has access to the necessary tools and structures to allow it to succeed. Make sure that team members understand why they have been selected, and find ways to recognize their efforts. Ask the member from the quality improvement or performance improvement department to orient the team to key principles and approaches used in process redesign work. Ensure that the team has the information it needs about the scope of the problem of falls in your facility (e.g., fall rates, repeat fall rates, severity of injury), the reasons for the team's work, and the expected outcomes. Make sure the team meets regularly at the most convenient time and place and that it meets often enough to make progress. Develop a timetable for specific team tasks and assign members to be responsible for completing those tasks.

This Institute for Healthcare Improvement Web site ("Science of Improvement: Setting Aims") has guidance on setting team goals and other aspects of team startup: www.ihi.org/knowledge/Pages/HowtoImprove/ ScienceofImprovementSettingAims.aspx .

2.1.3. How does the Implementation Team work with other teams involved in fall prevention?

The remainder of this section discusses activities that the Implementation Team will typically be charged with, but the Implementation Team cannot carry out the entire program alone. The Implementation Team will need to collaborate with at least the staff who provide routine patient care in any unit where changes are to be implemented. These staff may be physically based on the unit (e.g., nurses or nursing assistants) or may be assigned to work with specific units (e.g., rehabilitation therapists, pharmacists, or physicians). We call these staff the Unit Team. Both teams have unique responsibilities but communicate and work together to make the program a success.

The Implementation Team will look at the big picture, including strengths and opportunities in current practices and the current status of prevention and fall incident reporting. This team will then identify needed changes and the specific practices, tools, and resources needed to implement these changes. Unit Teams, with members also represented on the Implementation Team, will actually implement the changes, integrating them into existing workflows and providing feedback about how the changes work. The Unit Team should include staff from all shifts and will have ongoing responsibility for maintaining effective fall prevention practices.

No single team can make the program a success by itself. To help develop the Unit Team, the Implementation Team should:

• Outline roles for the Unit Team members that are clear and workable.
• Consider each Unit Team member's existing responsibilities on the unit and how the unit team member's new role interacts with those responsibilities.
• Define what ongoing communication and reporting are needed and what the best linking methods across the Unit Team and the Implementation Team might be. For instance, in some organizations, Unit Champions provide this coordination function. Unit Champions belong to both the Implementation Team and their own work units and thus serve as critical communication links.

Keep in mind that there is more than one way to organize. A useful guide is to consider how Implementation Teams for other clinical change efforts have operated successfully within your organization. Your organization's quality improvement or performance improvement experts are likely to have expertise in how to best organize and coordinate such teams. In many hospitals, the training and development area may also be a resource for team organization expertise.

Clarify the Unit Team's roles in the change process. Define the communication that is needed and the methods for linkages across teams.

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2.2. What needs to change and how do you need to redesign it?

In this section, we identify the steps the Implementation Team needs to take to assess the current state of policy, procedures, and practice, and we indicate tools that may be useful in this process. These steps are based on the principles of quality improvement, defined broadly to include system redesign and process improvement. These methods are appropriate for an effort that seeks to prevent falls by improving quality of care.

2.2.1. How do you start the work of redesign?

For the Implementation Team, the work of redesign has already begun through gathering the information about organizational readiness (go to section 1) and defining the team's members and structure. This quality improvement process may already be familiar to your organization. If you are not sure about the strength of your organization's quality improvement infrastructure, you may want to complete Tool 2B, "Quality Improvement Process."

Committees that oversee quality improvement for the hospital may go by different names, such as Quality Council or Patient Safety Committee. If some of the quality improvement processes listed in this inventory are not fully operational or present in your organization, you may need to build your team's improvement capability. In addition to identifying team members with improvement expertise, the Implementation Team can develop basic improvement skills through an education process.

Improvement efforts tend to be most successful when teams follow a systematic approach to analysis and implementation, and there are multiple approaches to consider. Team leaders and members may want to consult more general resources for approaches to quality improvement projects, such as information on the Plan, Do, Study, Act (PDSA) approach (described below in "Practice Insights").

If your organization already has well-established quality improvement processes and structures, it will be beneficial to connect the fall prevention program with those processes. For example, if you have an established reporting structure to leadership, including this program will help keep it on the leadership agenda. If managers are already evaluated based on their quality improvement efforts and results, making this program a part of the large quality improvement enterprise in your organization will help ensure managers' interest.

	Assess your organization's current resources for quality improvement by completing the "quality improvement process inventory" found in the Tools and Resources section (Tool 2B, "Quality Improvement Process").
	This Institute for Healthcare Improvement Web site ("Science of Improvement: Testing Changes") includes a brief summary of the PDSA cycle and a clinical example of it in use: www.ihi.org/knowledge/Pages/HowtoImprove/ ScienceofImprovementTestingChanges.aspx .
	Examples of Improvement Processes PDSA (Plan, Do, Study, Act) PDSA is an iterative process based on the scientific method in which it is assumed that not all information or factors are known at the outset; thus, repeated cycles of change and evaluation will be needed to achieve the goal, each cycle closer than the previous one. With the improved knowledge, you may choose to refine or alter specific goals. For more information, refer to Chapter 5 in the RAND report Putting Practice Guidelines to Work in the Department of Defense Medical System. A Guide for Action, available at www.rand.org/pubs/monograph_reports/2007/MR1267.pdf [Plugin Software Help] . Johns Hopkins Translating Research Into Practice (TRIP) Model This model elaborates a specific strategy for researchers, clinicians, and managers to collaborate in quality improvement. The model uses 4 "E's" (Engage, Educate, Execute, and Evaluate) and has been successfully applied in both large-scale quality improvement (QI) collaboratives and small-scale, clinically focused QI projects at the individual unit or hospital level. For more information, refer to: Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008;337:a1714. A practical case study applying this model at an individual unit level is described in:  Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehabil 2010;17(4)271-81. Six Sigma Developed at Motorola, Six Sigma methodology is based on the careful analysis of data on process deviations from prespecified levels of quality and use of redesign to bring about measurable changes in those rates. Six Sigma incorporates a specific infrastructure of personnel with different levels of training in the method (e.g., "Champions," "Black Belts") to take different roles in the process. For more information, read "What Is Six Sigma?" at: www.motorola.com/web/Business/_Moto_University/_Documents/ _Static_Files/What_is_SixSigma.pdf. LEAN/Toyota Production System (TPS) TPS is an integrated set of practices designed to systematically and continuously identify problems at the point of production and empower workers to identify and fix problems when they are identified. For more information, refer to "Reducing Waste and Inefficiency in Health Care Through Lean Process Redesign: Literature Review."
	Further reading relevant to quality improvement: Rogers EM. Diffusion of innovations. New York: Free Press; 2003. Langley GJ, Nolan TW, Provost LP, et al. The improvement guide: a practical approach to enhancing organizational performance. 2d ed. San Francisco: Jossey-Bass; 2009.

2.2.2. What is the current state of your fall prevention practice?

The work of redesign requires an assessment of your organization's current practices. In addition to the tools suggested below, you may want to look ahead to section 5 for additional tools for assessing current fall rates and care processes to prevent falls. We suggest looking carefully at the gap between current practice and the recommended practices discussed in section 3. For example:

• Do any care processes already follow best practices?
• Do others diverge in small ways or in major ways?
• Which gaps are organizationwide, and which are specific to one or more units?

If your hospital is large and complex enough that you suspect variation in current practice across units, the Implementation Team may want to start by focusing on one or two units.

Understanding the Organizational Context of Fall Prevention Practice

As a preliminary step in documenting prevention practices on the units, the team will need to review the organizational context for the practices. Among the questions to consider:

• Have there been prior efforts to improve fall prevention? If yes, are there lessons on which you can build? For example, what supported those efforts? What barriers were encountered and how can you avoid the same problems?
• Are staff who prescribe and review medications (e.g., physicians and pharmacists) involved in fall prevention practices? In what ways? What are their attitudes?
• How are rehabilitation staff involved in fall prevention? In what ways do rehabilitation staff and nurses coordinate their efforts to prevent falls?
• How is information about patient fall risk factors documented and shared? What metrics, if any, are currently used to assess organizational performance with respect to managing these risk factors?

Understanding Current Processes on the Units

To change practice, it is critical to understand what the current practices are. The fact that fall prevention has taken on new urgency reflects one or more perceived performance problems in this area. Thus, it is important to identify any gaps between current best practices and actual work practices. For example, staff may report a policy of accompanying all patients with abnormal gait to the bathroom but may not always do this. The extent of these gaps is usually not known until current practice is systematically examined. Understanding where any unit that is targeted for change is starting from will help you identify gaps in knowledge and resources and will allow you to see how much progress is made.

Process Mapping To Document Current Practices

One useful approach to understanding current practices is to use process mapping to examine key processes where fall prevention activities could or should be happening. (Detailed instructions on process mapping may be found in Tool 2C, "Current Process Analysis").

Mapping can specify which organizational unit or person carried out each step in the process, with particular attention to both the movement of the patient and the movement of information about the patient. The goal of process mapping is to come to a common understanding of how a particular care process is being carried out, which then leads to further discussion about how the process should be carried out.

There are different approaches to process mapping, but each approach provides a systematic way to examine each step in the delivery of a specific procedure or service. Experimentation with different approaches can be helpful during the redesign planning phase because each approach can provide different insights and answer different questions.

Integrating Change Into Current Work Routines

Beyond gap analysis and mapping of current practices, the team should consider how the recommended practices for fall reduction can be integrated into current workflow and processes, rather than layered on top of them. One way to approach this task is to systematically assess the barriers to using evidence-based practices. For example, if eligible patients are not being mobilized out of bed within a specific period of time from admission, what are the reasons? Is it due to a lack of staff awareness that this should happen? Is it because nobody has specific responsibility for this task? Is it because staff lack training in how to mobilize patients or document that they did so?

	Assess current practice on a sample of representative units to determine which, if any, fall prevention practices are already in place (see sections 3 and 5). For example, is an initial risk factor assessment completed within a certain timeframe of admission? Are the results used to determine risk factors that can be intervened upon? Use process mapping to describe current prevention practices and to identify problem points. Process mapping will enhance understanding of how and when fall prevention fits into existing processes such as surgical or medical admissions, or admissions through the emergency department. Compare assessment results across units to determine which prevention challenges are organizationwide and which may be unit specific. Determine which practices need changing and consider how the new practices can be built into ongoing routines (discussed in section 4.1).
	This worksheet in Tools and Resources has a possible approach to process mapping (Tool 2C, "Current Process Analysis"). Use these worksheets to assess existing fall prevention practices in your facility (Tool 2D, "Assessing Current Fall Prevention Policies and Practices").
	If you would like to learn more about process mapping, the AHRQ publication, Toolkit for Redesign in Healthcare provides a detailed example and data collection tools.

2.2.3. What is the current state of staff knowledge about fall prevention?

Due to turnover, differences in training, and other factors, staff members will likely vary in their knowledge of recommended fall prevention and treatment practices. To address these gaps through education, you need to know what the gaps are. Thus, assessing the current state of staff knowledge is critical.

One assessment tool is the Fall Knowledge Test (Tool 2E), which was developed through a consensus process and used in a randomized controlled trial to measure nurses' knowledge about falls and their prevention (see box below for details).

By themselves, assessment of knowledge and training focused on increasing knowledge are not enough. Training needs to be integrated with current work routines (go to section 4.3.4). Based on analysis of the knowledge test results, the team can assess barriers to change among the staff that most likely will need to be addressed, a process that began with assessing their attitudes, as suggested in section 1. These barriers can be discerned through the assessment of staff knowledge and assessment of current practice. For instance, do staff believe that risk factor assessment is unnecessary because preventive procedures are applied to "everyone"? Keep in mind that not all barriers may be evident at the outset, so it is important to be attentive to potential barriers as the first wave of changes are implemented.

	Administer an inventory of fall prevention knowledge to staff members. See the tool listed below for this task. Consider collecting information on unit and occupation of respondents so that you can use this information to analyze results and better target training. Since this is an educational needs assessment, we do not recommend asking staff to include their names, unless they want direct feedback on their score. Using names may decrease participation. Develop methods to correct knowledge gaps and misunderstandings.
	The following tool can be used to assess staff knowledge: Staff Knowledge Test (Tool 2E, "Fall Knowledge Test").
	A 14 multiple-choice question knowledge test was administered before and after staff education following implementation of the Singapore Ministry of Health Fall Prevention Clinical Practice Guideline. For more details, refer to: Koh SLS, Hafizah N, Lee JY, et al. Impact of a fall prevention programme in acute hospital settings in Singapore. Singapore Med J 2009;50(4):425-32.

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2.3. How should goals and plans for change be developed?

2.3.1. What goals should you set?

Once the Implementation Team completes its analysis of the gaps in fall prevention, the team will need to review the evidence on various best practices (discussed in section 3) that may help address those gaps. However, before turning to those steps, the Implementation Team will need to set goals for improvement. These goals should be related both to outcomes (e.g., a reduction in falls per 1,000 bed days) and to processes (e.g., adherence to hourly rounds).

Goals should be related to data the hospital already collects or can collect (e.g., through incident reports or a chart audit). External benchmarks should be used with caution, since fall rates vary substantially by hospital unit (go to section 5). Goal-setting will help determine the team's next steps to redesign fall prevention activities within your hospital.

Once goals are chosen, your gap analysis may reveal problems in performance related to care processes such as these:

• Staff are not conducting the initial fall risk factor assessment within 24 hours of admission.
• Patients' medications are rarely reviewed for fall risk.
• Patients who are at risk for prolonged weakness from their hospital stay are not mobilized within 48 hours of admission.
• Patients with frequent toileting needs are not assisted in a timely fashion.

In this case, you may want to set goals related to the improvement of these measures to certain levels within a certain timeframe, such as improving the number of at-risk patients who are mobilized within 48 hours from 50 percent to 75 percent over the next 3 months. Alternatively, you may find that after you examine staff knowledge, certain gaps should be addressed. Other reasons for poor performance could be confusion in roles or a lack of staff communication. In these cases, goals could be set for addressing and improving these issues within a certain timeframe.

Set goals for improvement based on outcomes and processes. Identify benchmarks against which to judge goals and progress. Use goals to guide next steps in redesigning fall prevention.

2.3.2. How do you develop the plan for change?

Once goals have been set, the next step is to begin developing a more specific plan for implementing new practices and for assessing that plan through the consistent collection and analysis of data. This plan will be extended and refined by work to be completed in response to additional questions (described in section 4).

While this plan will need to be flexible to meet the needs of specific units, a comprehensive plan is still necessary. The best practices that will be discussed in section 3 are critical to the implementation plan but are not enough, as they must be implemented within the context of many other factors. Also, it is important to begin thinking early about sustaining the improvements you put into place (as discussed in section 6). Thus, the implementation plan should address:

• Membership and operation of the interdisciplinary Implementation Team.
• Standards of care and practice to be met.
• Ways gaps in staff education and competency will be addressed.
• Plans for rolling out new standards and practices, where needed.
• Staff accountable for monitoring the implementation.
• Ways changes in performance will be assessed.
• Ways this effort will be sustained.

The "plan of action" found in Tools and Resources can be a useful template for developing your implementation plan (Tool 2F, "Action Plan").

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2.4. Checklist for managing change

The checklist for monitoring your progress on completing the managing change activities can be found in Tools and Resources (Tool 2G, "Managing Change Checklist").