Hospital-Based Fall Program Measurement and Improvement
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):
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.
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.
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).
Safe culture is further strengthened by strong interdisciplinary teams, which includes collaboration and cooperation among leaders, nursing staff, and staff from other disciplines. 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.
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:
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 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.
Components of a Safe Culture
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. 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
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.
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