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Master's Projects and Capstones Theses, Dissertations, Capstones and Projects

Winter 12-20-2019

Implementing a Fall Prevention Program: A Quality Improvement

Project to Promote Patient Mobility on the Medical-Surgical Unit
Alba Araiza
University of San Francisco, [email protected]

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Recommended Citation
Araiza, Alba, "Implementing a Fall Prevention Program: A Quality Improvement Project to Promote Patient
Mobility on the Medical-Surgical Unit" (2019). Master's Projects and Capstones. 1091.
https://repository.usfca.edu/capstone/1091

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USF Scholarship: a digital repository @ Gleeson Library | Geschke
Center

Nursing and Health Professions Faculty School of Nursing and Health Professions
Research and Publications

Winter 12-20-2019

Implementing a Fall Prevention Program: A Quality Improvement

Project to Promote Patient Mobility on the Medical-Surgical Unit
Alba Araiza

Follow this and additional works at: https://repository.usfca.edu/nursing_fac

Part of the Nursing Administration Commons, and the Other Nursing Commons
IMPLEMENTING A FALL PREVENTION PROGRAM 1

Implementing a Fall Prevention Program: A Quality Improvement Project to Promote Patient

Mobility on the Medical-Surgical Unit

Alba Araiza

University of San Francisco

IMPLEMENTING A FALL PREVENTION PROGRAM 2

Abstract

Implementing a fall prevention program is imperative in acute healthcare settings. Falls

are one of the top reported events that occur in hospitals and it is a patient safety concern that

requires the implementation of evidence-based practices to reduce falls. This quality

improvement project will be developed by a master’s prepared clinical nurse leader (CNL) on a

medical-surgical unit to improve patient safety.

Problem

Maintaining patient safety is the most important priority in health care. Health care

organizations implement protocols, policies and procedures to ensure that care is provided in a

safe manner to minimize preventable harms. However, falls are unexpected incidences that occur

in health care settings but are considered to be preventable occurrences. Falls can lead to serious

injuries and even death; these events are known as sentinel events (The Joint Commission [TJC],

2013).

According to the TJC (2016) inpatient falls are one of the top reported sentinel events

occurring in hospitals and are considered a serious problem because it compromises patient

safety. According to Walsh et al. (2018) and Zhao et al. (2019) in the U.S. the average fall rate of

adults in a medical and surgical (M/S) unit is 3-5 falls per 1,000 patient days, in which 26.1%

result in serious injuries including death. The existing problem in a Medical-Surgical (M/S) unit

is that there was a 44% increase in falls this year in comparison to the previous year. Therefore,

implementing a fall prevention program focusing on patient mobility is imperative.

Context

The M/S is an inpatient unit that has three floors with a total of 110 beds that serves a

diverse population of patients. The M/S unit provides medical services adult patients. The unit
IMPLEMENTING A FALL PREVENTION PROGRAM 3

provides treatment for acute and chronic medical conditions such as cardiovascular, pulmonary,

and renal diseases as well as others. The M/S unit has been diligently working on focusing on

purposeful hourly rounding as a method to decrease in patient falls but it has not yielded the

desirable outcome of a reduction in falls.

Interventions

The proposed plan is to implement a fall prevention program that is centered around

promoting patient mobility on the M/S unit to decrease patient falls. The CNL will establish a

multidisciplinary team known as the mobility/fall task force to collaborate on developing a

standardized mobility program that can be modified to meet the needs of each patient. This

program will be multifaceted as it will also include performing a fall and mobility assessment

and the use of several mobility tools in place along with the development of a patient mobility

goal plan tool that will be incorporated into this fall prevention program. The goal is to reduce

the incidence of inpatient falls occurring in the M/S unit by 25% by the end of December 2019

and 50% by December 2020. This program is currently underway.

Measures

To determine the success of this project, several data sets will be collected by auditing

nursing documentation of the following: nursing fall risk and functional mobility assessments,

patient daily mobility activities, and hourly rounding. Additional data will be collected through

the review of incident fall reports as well as the review of monthly length of stay. These

measurements will be analyzed first on a weekly basis for two weeks, followed by a bi-weekly

basis for four weeks, then monthly for six months, and every three months thereafter. The data

collected will then be entered in a Microsoft Excel spreadsheet to graph the information to depict
IMPLEMENTING A FALL PREVENTION PROGRAM 4

the changes occurring over time. The graphs will reflect if there are any changes indicating

positive outcomes through the introduction of this fall prevention program.

Results

The fall prevention program was initiated in August 5, 2019 and trialed for two weeks on

all three floors in the M/S unit. The program officially began on August 19, 2019. The outcomes

measured included fall rates, percent of patient being ambulated and length of stay. At this point,

there is insufficient data available to determine the trend of the success, but the initial results

indicate positive outcomes since the program was implemented. Although it is not the target goal

of 25% reduction, data indicates that there has been a 7% reduction in falls. Further, data shows

that there also was a decrease in length of stay (LOS). However, the percent of patients being

ambulated was below the desired target goal.

Conclusion

The preliminary results indicate that having the CNL implement and lead the fall

prevention program has shown positive outcomes in the reduction of falls occurring in the M/S

unit per month. To continue the success of the program, the CNL will continue working closely

with staff to assign a unit champion by floor per shift to ensure sustainability. The mobility/fall

task force will continue meeting regularly to monitor success of the program and discuss ways to

continue preventing falls. The success of this program will indicate that having a CNL

collaborate with a team to implement quality improvement projects can lead to improved patient

safety and better patient outcomes.

Keywords: Clinical nurse leader (CNL), quality, patient safety, staffing, improvement
IMPLEMENTING A FALL PREVENTION PROGRAM 5

A Quality Improvement Project to Promote Patient Mobility on the Medical-Surgical Unit

Introduction

The M/S unit is a microsystem that has a total of 110 single-bed private rooms available

on three floors to provide care to patients being admitted for treatment of acute and chronic

medical conditions, for surgical intervention, acute rehabilitation and for medical observational

purposes. The M/S unit provides medical services to people ranging in ages from young adults to

the elderly. The primary age group served is 55 years and older. Primary diagnoses are chronic

obstructive pulmonary disorders (COPD, congestive heart failure (CHF), pneumonia, end-stage

renal failure (ESRD), diabetes and rule out tuberculosis as well as other diagnoses.

There are three floors in the M/S unit and each floor serves a specific group of

population. 2S is a 30-bed floor designated to provide post-operative care to all surgical patients

and general M/S patients. 3S is a 30-bed floor designated to care for general M/S patients,

however, 22 of the beds are for general patients and eight beds are designated to be used for

acute patient rehabilitation (APR). 4S is also a 30-bed floor and cares for general M/S patients.

2W is a 12-bed floor designated for overflow use when all three M/S floors are occupied at

capacity. Finally, there are 8-beds that are located in the emergency department designated as

M/S observation rooms for patients that do not met the criteria to be admitted as inpatients but

have symptoms that require medical monitoring and intervention. On average, the daily census

ranges from 20-30 patients per floor.

Statement of the Problem

This year, in comparison to the previous year, the M/S unit has experienced an alarming

increase in falls. To date (January thru November 2019) the M/S unit has had 46 patient falls

which is a 44% increase in falls occurring this year in comparison to the previous year
IMPLEMENTING A FALL PREVENTION PROGRAM 6

(Appendix A). Last year, the M/S unit had 32 falls for the entire year. Thus far, from the 46 falls

that have occurred, four patients sustained minor injuries (i.e. one had bruising, one had

abrasions, one had skin tears), two patients sustained moderate injuries (i.e. one required

splinting of arm and one splinting of the knee), three sustained major injuries (shoulder fracture,

hip fracture, and knee fracture), and two patients have died secondary to sustained fall (Denise

Pogue, Director of M/S unit, personal communication, August 18, 2019).

Unfortunately, the two deaths that occurred as a result of the falls are considered a never

event which is a medical error that should never occur (Patient Safety Network [PSNET], 2019).

The fact that these two incidences transpired indicates that there are some serious safety concerns

within the unit. These safety issues can be attributed to inadequate nursing assessments,

communication failures, lack of adherence to protocols and safety practices, and lack of

leadership (TJC, 2015). Furthermore, the average cost associated with these events is

approximately $58,800 per injury which can result in an approximate cost of $2.5 million in

additional expenses (Bernazzani, 2017). Therefore, it is evident that there is a need to implement

a fall prevention program to address the existing patient safety issue.

The substantial rise in falls occurring on the M/S unit has led to the need to implement a

quality improvement project. The executive directors and management is vastly invested in

addressing this issue through the development of a program that will reduce the falls occurring

on the unit. In response, the CNL is taking on the lead on this project and developing the nurse-

driven fall prevention program using the Plan-Do-Study-Act (PDSA) cycle. The aim of the

project is to implement a culture of change in which staff will prioritize mobility as an

intervention to reduce risk for falls. The goal of this study is to identify the barriers preventing
IMPLEMENTING A FALL PREVENTION PROGRAM 7

staff from promoting and encouraging patient mobility while in the M/S unit. This project is

supported by the executive staff and department manager.

The initial phase of this project began with the CNL developing a program that focused

on promoting patient mobility to assist in reducing a patient’s risk for fall. The goal is to improve

patient safety by reducing falls. The CNL will work closely with a multidisciplinary mobility/fall

task force team that will be comprised of various members which include registered nurses

(RNs), certified nursing assistants (CNAs), physical therapists (PT), medical doctors (MDs),

nurse educator, clinical information system analyst, and RN case managers (RNCM). The team

will use the PDSA cycle to develop the fall prevention program.

In order to determine the root cause for the increase in falls in the M/S unit, the CNL

along with the team created two fishbone (cause and effect) diagrams (Appendix B & C) to

identify the potential factors and barriers contributing to the increase in falls. After analyzing the

cause and effect, the findings indicated that there were a number of factors contributing to the

rise in falls but it was determined that the primary issue was related to lack of mobility. In order

to begin this fall prevention program, it was necessary to create the workflow process map

(Appendix D) and conceptual model (Appendix E) showing the steps and flow of the processes

in place. The intent of creating this process map and conceptual model was to create a step-by-

step depiction of the existing processes in place to identify any barriers in the process. The

workflow process identified that the primary barrier is related to lack of prioritizing mobility.

Therefore, findings indicated that mobility should be the primary focus of this project.

The CNL and mobility/fall task force team developed a Likert scale five-point survey

(Appendix F) that was conducted to identify gaps in knowledge and attitude staff has toward
IMPLEMENTING A FALL PREVENTION PROGRAM 8

prioritizing mobility, identify knowledge deficits, and identify staff resistance in implementing

the necessary changes to prevent patient falls.

All staff members responsible for providing direct patient care were surveyed. A total of

180 staff members were surveyed and 123 responses were received. The data collected identified

the existing barriers and allowed the CNL an opportunity to address these barriers through this

project. After reviewing the data collected from the responses received, the overall responses

indicated that staff considers patient mobility to be a priority but time constraints is the primary

factor for not making mobility a priority when providing care (refer to Appendices G, H, I, and J

for survey results).

Currently, the RNs perform a fall risk and BMAT level assessment using the Morse Fall

Score (MFS) to identify a patient’s risk for a fall along with the Banner Mobility Assessment

Tool (BMAT) to identify a patient’s baseline mobility level (Refer to Appendix K) which was

recently implemented through another quality improvement project. The BMAT is a tool

intended to be used to determine a patient’s baseline mobility function in order to develop a

mobility plan during their hospital stay. The intent is to set mobility goals that patient must

achieve to maintain their functional mobility while in the hospital. However, it has been found

that no mobility plans and goals are being developed and implemented. Thus, patients are not

actively mobilized thereby increasing their risk for falls.

According to Melin (2018) the Centers for Medicare and Medicaid Services (CMS)

consider falls preventable incidences that occur in health care facilities which are events that

should never occur. According to TJC (2015) any patient is at risk for a fall when there is a

change in their mental and physiological status which can cause them to become weakened or

confused.
IMPLEMENTING A FALL PREVENTION PROGRAM 9

There are some interventions that have been proven to be successful in preventing falls

such as establishing a fall prevention and mobilization program. According to Agency of

Healthcare Research and Quality [AHRQ] (2017) mobility decreases shorter term complications

including muscular weakness thus decreasing risk for fall. Healey (2011) provides that some

successful methods proven to prevent falls include but are not limited to reviewing and

discontinuing medications associated with increased risk for falls, continence management

through frequent toileting, hourly rounding, access to mobility aids/devices, mobility, and most

importantly staff and patient education.

Therefore, the proposed solution is developing this fall prevention program that will

prioritize mobility by promoting the need to mobilize patient and encouraging staff to focus on

making it a priority to mobilize patients. The goal of the project will be to have a reduction in

patient falls which will occur through staff awareness of the proposed fall prevention measures,

and through education, training, and reinforcement. The goal of the program is to have a 25%

reduction in falls by December 2019 and a 50% reduction in falls by December 2020. The CNL

will be assuming responsibility of this project.

Clinical Nurse Leader to Lead Project. A CNL is a nurse that has received a master’s

degree and has been prepared to address the need to improve the quality of patient care outcomes

within any healthcare setting (American Association of Colleges of Nursing [AACN], 2013).

This fall prevention program is a quality improvement project aimed at implementing a culture

change in practice within the M/S unit. The CNL will act as Clinical Outcomes Manager by

assuming leadership of this project and by forming the mobility/fall task force team to assist in

developing the fall prevention program.

IMPLEMENTING A FALL PREVENTION PROGRAM 10

The CNL has the knowledge and experience necessary to implement changes within a

microsystem. Further, the CNL has the ability to collaborate with the mobility/fall task force

team and frontline staff as well as management to improve the workflow process which is

essential to accomplish the goals of reducing falls within the microsystem. Moreover, the CNL

can assume the roles of change leader which is a key role in the implementation of process

improvement to establish and manage a formal change (TJC, 2019). Using a CNL is an approach

that can prove beneficial in addressing efficiency, empowerment, quality, and the behavioral side

of change (TJC, 2019).

Available Knowledge

To improve the quality and safety of patient care, evidence-based practice (EBP) should

be used to support the need to improve the nursing practice. Brand Erikson and Faber Frandsent

(2018) indicate that when developing a clinical research, the PICOT model is the frequently used

tool to structure the clinical research questions in connection with evidence syntheses. Milner

and Cosme (2017) further support that the PICOT process is a consistent, systematic way to

identify components of a practice issue, and a well-designed PICOT question increases the

probably of finding relevant evidence to inform and support the practice.

Thus, for this project the PICOT is as follows: in the M/S unit with adult inpatients (P),

how will developing a fall prevention program that focuses on promoting patient mobility to

reduce fall rates (I), in comparison to the previous years’ fall rates (C), reduce patient falls (O)

from 2018 to present time (T).

A search of the EBSCOhost platform, which includes the Cumulative Index to

Nursing and Allied Health Literature (CINHAL), Ovid, and Medline databases were used. A

search was conducted using the PICO search strategy of patient, adults, falls, fall risks, fall
IMPLEMENTING A FALL PREVENTION PROGRAM 11

prevention programs and hospitals. The keywords of adults, inpatient, falls, acute care, fall

risks, fall prevention programs, mobility, patient safety, patient falls, and inpatient falls

were used. The search provided an abundance of relevant articles that could be utilized to

support this project. There were over 40 related articles with dates ranging from 2010 to 2019

that were found based on the keywords used and four were deemed appropriate for this

project and selected for review. The articles included in this literature review describes the

identified risks factors leading to falls and provide support on ways to reduce falls. Additionally,

the articles had supportive findings that provided the support needed to develop a fall

prevention program that focuses on patient mobility to reduce inpatient falls in a M/S

unit.

Tzeng and Yin (2017) performed a qualitative study conducted on fall prevention

practices in adult M/S inpatient care units of 51 U.S. hospitals to identify the effectiveness of a

fall prevention program. It was found that the most common interventions to prevent falls were

using bed alarms (90%), implementing regular rounds (70%), using sitters (68%), and relocating

patients closer to the nurses’ station (56%). According to Tzeng and Yin (2017) research shows

that using these methods are not sufficient practices to prevent falls. Furthermore, evidence

indicates in addition to use of these methods, there also needs to be ongoing education that needs

to be provided to patients and staff on the importance of fall prevention methods, that rounding

needs to be purposeful, and that changes to plan of care need to be made when there is a change

in patient condition (Tzeng & Yin, 2017).

Zhao et al. (2019) reported that evidence indicates that inpatient falls and falls with injury

involve multiple factors which include intrinsic and extrinsic factors. Intrinsic factors are patient-

specific and extrinsic factors are hospital organizational factors, nursing staffing, and nursing
IMPLEMENTING A FALL PREVENTION PROGRAM 12

process factors (Zhao et al., 2019). According to Zhao et al. (2019) extrinsic factors are

considered to be a significant contributor associated with the falls that occur in hospitals. Zhao et

al. (2019) suggests that fall prevention interventions that can be developed and implemented

should include components that address (a) environmental, (b) educational, (c) communicational,

and/or (d) nursing process interventions. Further, Zhao et al. (2019) indicate that the evidence

supports that establishing fall prevention interventions that can be individualized to each patient

has shown positive results in preventing falls.

Dykes et al. (2019) conducted a study that implemented the use of the Fall TIPS

(Tailoring Interventions for Patient Safety), an evidence-based program that is becoming a

standard for engaging patients in a 3-step fall prevention process that consists of conducting a

fall risk assessment, developing a standardized prevention plan, and consistently carrying out the

fall prevention plan. According to Dykes et al. (2019) the study results indicated that using the

Fall TIPS resulted in a 25% reduction in falls. Although the results indicated that patients did

sustain falls even with the implementation of program, a control study was conducted and the

results indicated that the reason patients sustained falls was because they did not follow the fall

prevention plan (Dykes et al., 2019).

Spano-Szekely et al. (2019) conducted a study to evaluate a hospital’s fall prevention

program that used the evidence-based practice improvement (EBPI) model that was developed

using evidence-based practice (EBP) to improve patient safety. The program focused on

developing a culture shift that focused on education. The goal of the program was to educate

patients and staff on the importance of using appropriate methods in place to assist in preventing

falls. Further, it was emphasized that fall prevention programs require fall prevention plans to be

individualized. The study provided that placing all patients on standard universal safety
IMPLEMENTING A FALL PREVENTION PROGRAM 13

precautions was not a proper strategy to assist in fall preventions. According to the study using

this method led to a 54% reduction in falls (Spano-Szekely et al., 2019).

The evidence provided through the literature review offers sufficient data that supports

the need to incorporate the prosed interventions and fall prevention strategies through this fall

prevention program to successfully reduce patient falls. Therefore, this fall prevention program

will incorporate several of the EBP methods found through the research that have been proven to

be effective in reducing falls.

Rationale

Falls occur due to a combination of multiple factors such as an unfamiliar environment,

acute illness, prolonged bedrest, and many other reasons. Indications for an increased risk for

falls is the presenting illness, the use of medications, and muscular and skeletal age-related

changes that increases the risk for loss of muscle tissue and weakness if patients are not

mobilized during hospital stays (Dermody, 2016). Falls are also attributed to patients not

receiving the nurse-promoted mobility needed to maintain independent physical function.

Furthermore, studies indicate that nursing care coordination is growing more complex

causing RNs to encounter many barriers deterring them from promoting patient mobility

consequently placing less priority on patient mobility (Dermody, 2016). Moreover, Dermody

(2016) stated that basic mobility in hospitalized patients through promotion of ambulation and

active and passive range-of-motion is a nursing responsibility.

However, the primary barriers attributed to nurses not mobilizing patients are due to

knowledge, attitude, and perception of external barriers and other influences on their behaviors

(Dermody, 2016). Consequently, prolonged immobilization results in functional decline, hence

IMPLEMENTING A FALL PREVENTION PROGRAM 14

increasing risk for fall (Dermody, 2016). Therefore, mobilizing patients is strategy that can be

enforced to help reduce risk for falls.

Specific Project Aim

The project aims to improve patient safety by promoting mobility to reduce falls on the

M/S unit by 25% by December 2019 and 50% by December 2020. The process will begin with a

nursing assessment to determine a patient’s fall risk score and their baseline mobility level. The

MFS and BMAT are tools that are used to evaluate patients fall risk score and functional

mobility level. The process will end with collaborating with the care team to develop

individualized mobility plans with set goals a patient should meet to encourage and promote their

involvement in their care and actively participate in mobilizing throughout their hospital stay. By

working on this process, it is expected to reduce patient falls, prevent patient deconditioning,

reduce length of stay and readmissions, and ultimately improve patient safety and satisfaction.

For these reasons, it is crucial to implement this fall prevention program because increased falls

can lead to increased length of stays, can lead to deconditioning which leads to more discharges

to skilled nursing facilities instead of home, and it also increases costs to the hospitals.

Methodology

The decision to implement a fall prevention program derived from the findings after

performing an Institute for Healthcare Improvement (IHI) culture assessment using the patient

safety self-assessment tool, completing a 5P assessment of the microsystem and doing a

strengths, weaknesses, opportunities, and threats (SWOT) analysis. Based on the data collected

and analyzed, findings indicated that there were several areas that required improvement within

the microsystem. The findings supported the need to improve patient safety by developing a

program designed to reduce patient falls. Implementing this project also required establishing a
IMPLEMENTING A FALL PREVENTION PROGRAM 15

culture of change within the microsystem. The success of the project largely depends on staffs’

willingness and cooperation in embracing the culture of change. To establish the necessary

culture of change, the CNL used Kotter’s eight-step change model.

SWOT Analysis

A gap analysis was initially performed by the CNL and team members for this project to

determine the root cause leading to increased patient falls within the microsystem. Using the

Strengths, Weakness, Opportunities, and Treats (SWOT) analysis (Appendix L), it was identified

that there was no priority placed on patient mobility in the microsystem. Although there were

many identified strengths in the unit, there were several weaknesses indicating that staff did not

recognize and understand the importance of prioritizing mobility.

A strength that was found is that the organization recognizes the need to support the

development of a fall prevention program and there is a desire to reduce falls. Additionally,

another strength is that staff has been trained on the use of the BMAT tool along with established

standards and procedures for the use of BMAT to assess patient’s mobility level. Other strengths

included the push from management to focus on purposeful hourly rounding, use of a fall

contract, use of bed and chair alarms, as well as staff understanding the importance of mobilizing

patients.

However, many of the weaknesses noted are that staff is not prioritizing the need to

mobilize patients and that they are not using the BMAT assessment tool as intended. Also, staff

does not educate patents on the importance of mobilizing during hospitalization. Additionally,

staff is not utilizing the fall contracts. Furthermore, based on a staff survey conducted it was

determined that staff indicated that the main reason patients were not mobilized was because of

time constraints.
IMPLEMENTING A FALL PREVENTION PROGRAM 16

The opportunities found were the prospect of reducing fall rates, improving patient care

outcomes, reducing LOS and readmissions, improving patient safety and satisfaction, and

increasing staff compliance for fall prevention practices.

The threats found was staffs’ non-compliance with use of BMAT tool to develop a

mobility plan, staffs lack of ability to effectively time manage, increased LOS due to injuries

sustained from falls, increased costs associated with treating sustained injuries from falls.

Based on this SWOT analysis, the data supports the need to implement a fall prevention

program to decrease falls within the microsystem. Promoting patient mobility will not only assist

in decreasing the risk for falls but preventing patient falls is a requirement that TJC strives to

attain and considering that the organization has had two never events occur as a result from the

falls it is evident that patient safety is a serious issue that needs to be addressed.

Culture of Change

In effort to establish a culture of change that incorporates the implementation of this fall

prevention program, the CNL used Kotter’s eight-step change model to promote change

(Appendix M). Kotter’s eight-step change model was used to implement evidence-based

practices necessary to develop, facilitate, and sustain an environment that focuses on preventing

patient falls on the M/S unit. Kotter’s eight-step change model includes creating urgency (the

need for change), building the guiding team, getting the right visions, communicating buy-in,

empowering action, creating short-term wins, don’t let up, and making it stick (Su, 2016).

According to Su (2016) the key is to identify the primary stakeholders needed to develop

the change, then to form the team to focus on establishing the project’s aim and goals to be

accomplished, followed by assigning the roles and responsibilities of each member in the team.

The most important aspect is to obtain buy-in from staff to accept the need for change and
IMPLEMENTING A FALL PREVENTION PROGRAM 17

actively participate in adapting to the new practice. Further, it is stressed that having the team

leaders empower staff to accept the change and become active participants in the change process

is essential.

Using the Kotter’s eight-step model of change allows CNL and the mobility/task force

team to develop the plan and gradually implement changes and continue to reinforce changes

until the process is standardized. The key is to not let up. This requires keeping momentum of

project and enforcing staff compliance through reward of positive behaviors. The team should

also identify champions to ensure acceptance of the desired culture change. This requires

assigning a unit champion by floor per shift to take the lead on reinforcing the culture change

and to provide guidance and education as needed.

Further, the CNL will use the Six Sigma to define, measure, analyze, improve, and

control process to uncover the contributing factors and root causes for falls and falls with injury

(TJC, 2019). Therefore, it was imperative for the CNL to begin the fall prevention program using

the PDSA model for implementing an improvement project to establish a plan intended to

promote patient mobility.

The intent of the PDSA (Appendix N) it to first plan the project by strategizing the

objectives and the goals that are to be accomplished, to develop the timeline for the project

completion, and to develop the tools necessary to implement the program. The next step is do

which includes presenting the proposed project to appropriate staff members, implementing the

program, conduct audits, collecting and monitoring data, and providing support to staff. The

following step is to study the data, compare the results, summarize findings, and report them.

The final step is the act which is to present results to management and implement new

recommendations and begin the next phase of the project. Implementing a quality improvement
IMPLEMENTING A FALL PREVENTION PROGRAM 18

project requires undergoing a continuous improvement process for tests of change as depicted in

the continuous PSDA cycle (Appendix O).

The program began with the CNL developing a standardized physician activity order that

includes orders to ambulate three times a day. This order will prompt a task that will ensure staff

documents activity in the patient’s electronic health record (EHR). This is an essential step in

this process as this will be used to collect the data and analyze if there is a test in change.

Additionally, conducting a nursing fall risk assessment using the MFS and a functional mobility

assessment using the BMAT tool to determine a patient’s mobility level is equally important.

This will allow for data to be collected to determine whether a nursing assessment is being

performed and documented to establish a patient’s fall risk level and baseline functional mobility

level during admission or throughout their hospitalization.

During data collection and analysis, findings provided evidence supporting that not

having an established baseline mobility level for a patient leads to patients not being actively

mobilized and thus increasing their risk for a fall due to deconditioning and a prolonged hospital

stay. According to Kappel et al. (2018) ongoing assessment of a patient’s functional mobility

status can prevent immobility-associated complications.

The process calls for RNs to perform a Fall Risk and BMAT assessment at admission and

every shift thereafter. If there is a regression in mobility or no improvement noted it will prompt

staff to initiate a conversation with physician to considering placing physical therapy orders to

evaluate and treat patients showing deconditioning. However, from data collected through the

staff survey (refer to Appendix F) findings indicated that staff does not prioritize patient

mobility. As a result, the CNL developed a fall risk mobility tool as well as a magnet indicating a

patient’s mobility level and fall risk score. These are to be posted in the patient’s room and door,
IMPLEMENTING A FALL PREVENTION PROGRAM 19

respectively. These tools were designed to assist patient to mobilize by providing them with the

proper support and equipment needed to safety mobilize without compromising staffs’ and

patients’ safety because the fall risk mobility tool and magnet reflects the patient’s mobility level

(Lipsett & White, 2019). The fall risk mobility tool and magnet are user-friendly, easy to view,

and are laminated for multi-use purposes.

However, to encourage staff to make mobility a priority, it will be necessary to establish

a standardized process that will require RNs to implement a mobility plan with goals the patient

should meet to maintain their functional level. According to Klein et al. (2018) establishing an

individualized, nurse-directed, patient mobility program using duality mobility goals is a

successful strategy to improve daily patient mobility in the hospital.

The proposed plan is to implement a fall prevention program that is patient-centered and

will focus on promoting patient mobility on the M/S unit to assist in decreasing patient falls. The

CNL will be creating a standardized mobility program that can be modified to meet the needs of

each patient. This plan will be multifaceted as it will outline the various mobility goals a patient

should meet to ensure their baseline mobility level is reached or maintained while in the hospital.

It will also include assessment tools to determine the need to use any equipment to safely

mobilize patients.

The CNL developed the Patient Mobility Goal Plan (PMGP) tool (Appendix P) and is in

the process of fully enforcing the use of this tool. The PMGP tool is intended to encourage

patients to be involved in achieving their mobility goals by signing off every time they achieve

their goal for the day. The tool is a user-friendly visual chart that is easy to use. The goal is to

have patient indicate time and initial every time they have achieved their goal for the day. The

PMGP tool will be laminated for multi-use purposes and will be made available to all rooms in
IMPLEMENTING A FALL PREVENTION PROGRAM 20

all floors of the M/S unit. The tool was being reviewed by the fall prevention/mobility task force

team and management and was awaiting approval to print and begin use. The CNL received

approval mid-November and it awaiting printing. At this time, a printed copy is being used and

trialed on 3S. At this point, it is expected that utilization of this tool will be minimal at this time

but expected to reach above 65% within the next two months. The CNL was responsible for

ensuring that all staff receive an in-service on how to use the tool. The CNL provided a two-

week in-service of the fall prevention program along with the use of the PMGP tool to all staff.

The CNL provided the in-service during the morning, afternoon, and night shift safety huddles.

Furthermore, the CNL assigned a unit champion on each floor by shift and educated them on this

the fall prevention program. The goal of the unit champion is to ensure that staff continues

implementing the change strategy and to provide reinforced training and education on an

ongoing basis.

Guidelines were provided as well to ensure staff selects the proper equipment needed to

mobilize a patient based on the needs of the patients depending on their BMAT level. The RNs

will be responsible for assessing patients’ mobility and assigning the appropriate BMAT level to

establish the mobility goals and to determine the need to use any equipment to safely mobilize

patients. The RNs will utilize the PMGP tool to reflect times a patient is actively mobilized and

document the activity in the EHR.

It is anticipated that this fall prevention program will lead to a reduction in falls thereby

meeting the TJC patient safety goals and it will also provide a cost savings from a reduction of

the expenses to treat injuries sustained from falls.

IMPLEMENTING A FALL PREVENTION PROGRAM 21

Goals and Objectives

The primary goal of this program is to decrease inpatient falls on the M/S unit by 25% by

the end of December 2019. It is anticipated that once this program is fully implemented there

will be a 50% reduction in falls by 2020. To attain this goal, it is proposed that this fall

prevention program be implemented because falls can lead to serious consequences.

A patient can sustain injuries ranging from minor-to-major, and even death can result.

This creates serious complications and also it places a huge financial burden on hospitals as falls

occurring in hospital settings results in 6.3 additional days stay in the hospital and the average

cost for is $14,000 per patient (TJC, 2016). Moreover, falls compromise patient safety and

causes patient dissatisfaction because it causes patients to develop fear of falling, depression,

reduced mobility and functional ability, and it creates a financial burden to both patients and

healthcare facilities (Zhao, 2019). Therefore, there is a need to implement a fall prevention

program that is geared at reducing the risks for falls. This plan provides a cost-effective method

that staff can effortlessly implement and it has the potential to become a sustainable process that

can eventually be a part of the culture of safety within the M/S unit.

Promoting patient mobility will not only assist in decreasing the risk for falls, but it will

also lead to a decrease in LOS and readmissions, in addition to a cost-savings from a decrease in

the expenses related to treating injuries that occur from the falls. Subsequently, this fall

prevention program will lead to improved patient safety and satisfaction, increased monetary

savings, and it will also improve the nurses’ patient care satisfaction and encourage staff to make

mobility a priority in care.

Another benefit of implementing a fall prevention program is that it will show patients

and their families that their safety is important (Mitchell et al., 2014). Further, patients will be
IMPLEMENTING A FALL PREVENTION PROGRAM 22

discharged in a timely manner, the stress on the staff will be reduced leading to improved staff

retention which increases the continuity of care by having nurses stay longer on the unit (Jones &

Gates, 2007).

Intervention

There are some interventions that have been proven to be successful in preventing falls

such as establishing a fall prevention and mobilization programs. According to Agency of

Healthcare Research and Quality [AHRQ] (2017) mobility decreases shorter term complications

including muscular weakness thus decreasing risk for fall. Healey (2011) provides that some

successful methods proven to prevent falls include but not limited to reviewing and

discontinuing medications associated with increased risk for falls, continence management

through frequent toileting and hourly rounding, access to mobility aids/devices, mobility, and

most importantly staff and patient education.

Developing a mobility initiative to prompt patients to ambulate during their hospital stay

can also be used (Wexler & O’Neill, 2015). Therefore, the proposed solution is to develop a fall

prevention program intended to promote and encourage patient mobilization. The goal of the

project will be to have a reduction in patient falls which will be done through staff awareness of

fall prevention measures through education, training, and reinforcement. The conceptual model

was created to show the change concepts and objectives to be accomplished with this project.

Measures

To determine the effectiveness of the program, it will be necessary to do continuous

monitoring once the program is implemented to determine the success. This will require

establishing measures to compare the outcomes. The CNL will develop a tool to measure

outcomes and prevention practices and indicate the target goal to be accomplished (Appendix Q).
IMPLEMENTING A FALL PREVENTION PROGRAM 23

This tool will include outcomes measures (i.e. fall rates, monthly average of percent of patients

ambulated, and monthly average LOS in M/S patient), process measures (i.e. fall risk assessment

using the MFS, BMAT assessments, PMGP tool use, and use of BMAT magnets), and balancing

measures (i.e. number of falls per month).

The outcomes measures will be audited on a monthly basis for six months followed by

quarterly thereafter by the CNL and mobility/fall task force team. However, the CNL and team

will monitor the fall rates after each incident and the average LOS will be monitored on a

monthly basis. For the process measures, the CNL will audit the EHR and perform audits for use

of PMGP tool and BMAT magnets. The purpose is to monitor progress to determine success in

reaching target goal (Appendix R). The CNL will also conduct ongoing evaluation of

effectiveness of the program and provide reinforcement to ensure staff compliance. The CNL

will round on staff on a monthly basis to determine if they are actively promoting patient

mobility, establishing a mobility plan and setting goals, and to determine if staff is actively

mobilizing the patients. The CNL and team will gather appropriate data to evaluate and

determine the success of the fall prevention program.

Ethical Considerations

The ethical dilemma to consider when implementing this fall prevention program is the

patient’s right to autonomy. According to Quigely (2016) the American Nurses Association

(ANA) states that a core value and assumption is that the interaction between the nurse and

patient involves participation of both in the process of care. Moreover, of the core principles in

the nurse code of ethics is to have respect for a person’s autonomy or right to self-determination

(Quigely, 2016). Therefore, patient needs to be educated on the purpose of the fall prevention
IMPLEMENTING A FALL PREVENTION PROGRAM 24

program and provided with information that is evidence-based so that patient is able to make an

informed decision about their care.

Although this fall prevention program is designed to be patient-centered and to maintain

patient safety, the patient reserves the right to refuse to receive or engage in the care provided. It

is the nurse’s responsibility to inform patient of the choices they have such as participating or

refusing to participate. The nurse is obligated to inform patient of the consequences of their

choices such as increasing their risk for falls if choosing to not participate. Once the patient has

been informed they can make the choice that they feel is best for them and the nurse must respect

the patient’s decision.

Two-Year Budget Projections

There are several elements that need to be accounted for in order to develop a budget.

Foremost is the cost of materials and labor. Secondly, it is necessary to determine the cost to

treat patients when they sustain a fall. Another element that is often overlooked is the potential

additional costs from lawsuits filed for fall-related injuries.

The total anticipated budget expense to implement this program is estimated at $57,000

for the first year and $33,000 for the second year. An itemization of the projected estimated costs

for materials and labor was prepared to depict the costs associated with the project (Appendix S).

The expenses include materials and labor costs to provide training, for the use of office supplies

(i.e. paper, printer, and a computer), the purchase of new equipment (i.e. sara stedy), and the

consulting fees for technician to discuss and demonstrate proper use of equipment to staff

training. The budget also includes the labor costs to train all 120 RNs and 60 CNAs which is

based on the base pay (hourly) x time (three hours of training). The cost to pay the RN educator

to provide the education and training and the physical therapist (PT) to show staff how to
IMPLEMENTING A FALL PREVENTION PROGRAM 25

properly assess, determine appropriate equipment to use, educate staff on use of proper body

mechanics, and how to properly ambulate patients based on their functional level is also

included.

For the material, a rough estimate was created for the use of computer and printer, as well

as the paper and ink to print the agenda, the surveys, the PowerPoint presentation, etc. Further,

the equipment consultant determined that the microsystem would benefit from the purchase of

the sara stedy. The consult provided the estimated costs for the equipment in addition the

consulting fees to train and educate staff both which have been incorporated into the projected

estimated cost. Based on the safe patient handling regulations established by the Occupational

Safety and Health Agency (OSHA, 2016) in California, it was determined that it would be

required to purchase 10 lifts to meet the standards of safe patient handling for the first year.

Further, it was determined that another two sara stedy lifts would be purchased for the second

year.

The budget is projected on a two-year basis. The first year the cost is higher due to the

startup costs to implement the program. However, there is a large decrease in the cost because

the following year the costs merely include the reeducation of staff and the purchase of two

additional equipment to maintain the program the following year. Because of the feasibility of

this project, the cost to implement the program is minimal in comparison to the cost savings.

A small investment will be needed to initiate the program but, in the end, it will yield a

large cost savings once the program is fully in effect. The overall savings is projected to be an

average of $14,000 per patient in addition to a reduction in LOS based on the estimated average

of an additional 6.3 days to treat injuries (TJC, 2016). Also, a decreased LOS will make more
IMPLEMENTING A FALL PREVENTION PROGRAM 26

beds available for use which allows the M/S to admit patients thus increasing reimbursement

rather than a loss.

Financial Analysis: Cost Benefit Analysis (CBA). TJC (2016) estimates that the

average cost to treat a patient that sustained a fall while in the hospital is $14,000. The average

cost accounts for the associated fees to provide patient care, any additional treatment needed to

treat injuries, and the estimated increase in LOS which is projected to be an additional 6.3 days

(TJC, 2016).

A cost benefit analysis was conducted detailing the benefits of implementing the

program. The overall savings is projected to be an average of $14,000 per patient in addition to a

reduction of length of stay (LOS) based on the estimated average of an additional 6.3 days to

treat injuries (TJC, 2016). Therefore, the reduction on average cost to treat for serious injuries in

addition to a decrease in LOS will be the cost benefit to implement this program.

In the M/S unit there have been a total of 46 falls to date and based on the average cost of

$14,000, it equates to a total cost of $588,000 to treat patients with sustained falls. Therefore, by

reducing the falls by 25% in the first year it will yield a cost reduction by $147,000 in the first

year and by reducing the falls by 50% in the second year the cost reduction will be $294,000 for

the second year and thereafter.

The cost savings was projected based on the cost to treat injuries which is $14,000 then

multiplying that amount by 46 which is the total number of patients that have had falls on the

M/S unit which equals to a total projected cost of $588,000. A cost benefit analysis (Appendix T)

was created to show the expected cost savings from this program. The goal of the program is to

reduce the falls by 25% by the end of the first year (December 2019) and the projected savings
IMPLEMENTING A FALL PREVENTION PROGRAM 27

after the first year is estimated at $90,000 (based on estimated costs savings of $147,000 minus

the projected cost of $57,000 to initiate program).

Conversely, by the end of the second year, there is a projected cost savings of $261,000

(based on estimated cost savings of $290,000 minus the projected cost of $33,000 to maintain

program the second year). Hence, a projected average savings of $261,000 by the end of second

year it is expected after the program is fully integrated. The cost savings is anticipated to

continue to increase thereafter. Based on the anticipated cost savings, the expense to implement

this program will offset the expenses in executing it.

Timeline

The proposed timeline (Appendix U) is to develop the mobility program, develop the

patient mobility goal plan tool (Appendix P), prepare the training agenda (Appendix V), develop

the staff training educational plan (Appendix W), develop the staff training acknowledgment

form (Appendix X), enforce the use of patient fall contracts, and collaborate with RN educator to

educate staff on the fall prevention program by the beginning of August 2019. The staff will

receive training and education early August 2019 and it is anticipated that the fall prevention

program will be rolled out by August 19, 2019 and will have a 90-day grace period to allow staff

to acclimate to the change. It is expected that all staff be fully compliant by December 2019.

From inception of the program until December 2019 the CNL and team members will be

actively monitoring progress, evaluating effectiveness of the program, reinforcing staff to ensure

compliance and will provide gather and monitor data to evaluate progress and success of the

program. By the January 2020, the CNL and team will obtain the fall report and compare the fall

rates between August 2019 to December 2019. This will allow the CNL and team to analyze the

data ant determine effectiveness of the program. By March/April 2020, staff will receive
IMPLEMENTING A FALL PREVENTION PROGRAM 28

reeducation to ensure that staff continues to comply and to provide a refresher training session.

By December 2020, the CNL and team will evaluate the entire project and review the total falls

sustained within the first year of implementing the program and analyze the data to determine if

the project is feasible, if it is cost effective, and if it has yielded the desired benefits expected

through the use of the program.

To determine the effectiveness of the program, it will be necessary to do continuous

monitoring once the program is implemented to determine the success. This will require using

the established measures referenced above to compare the outcomes. The CNL and team will

conduct ongoing auditing to evaluate effectiveness of the program and to provide reinforcement

to ensure staff compliance.

Results

This program was designed to focus on promoting patient mobility and although the

survey conducted indicated that staff acknowledged the necessity to make patient mobility a

priority, there was a lot of resistance from staff when attempting to implement this project. When

the project was first proposed by the CNL, it was presented to management and staff as a

program designed to encourage patients to become more involved in their care and actively

participate in mobility activities. The CNL presented the PMGP tool and indicated that the tool

was to be utilized by the patient to document every time they achieved their mobility goals for

the day. The staff would then transfer the activities that occurred during their shift into the EHR.

The goal of the PMGP tool was to encourage patient participation. By having patient sign off

that they met their goals for the day, it would give them a sense of accomplishment and motivate

them to commit to meeting their goals during their hospitalization.

IMPLEMENTING A FALL PREVENTION PROGRAM 29

Further, the tool would allow the health care team to visually see a progression of

mobility and if an activity was not documented on the tool it will prompt the health care team to

inquire why it did not occur. Moreover, if activities reflect no improvement or a decline in

activity levels, it will further prompt the health care team to discuss the need to provide

additional support such as requesting for a physical therapy evaluation and treatment.

Prior to implementing the program, the CNL educated staff on how to develop an

individualized mobility goal plan by incorporating the fall risk assessment, the BMAT

assessment, the PGMP tool and the BMAT magnets. The CNL also educated staff on the

importance of involving patients in their plan of care to ensure that patients are in agreement

with the goals established. By having patients engaged in the planning process it would allow

them to feel that they are partaking in their care planning thus reducing their resistance to

participate. This proposed program received a lot of buy-in from staff and staff was committed to

implementing this program without any resistance.

However, management decided to move in a different direction. Management indicated

that they did not want patients to be held accountable for ensuring they met their mobility goals.

Management stated that patient care is ultimately staffs’ responsibility therefore staff should be

accountable for ensuring that the goals are met. The CNL then changed the strategy of the

program. The CNL performed a two-week in-service which required the CNL to re-educate staff

on the new expectations that requires them to mobilize patients and document activities

accordingly.

When the revised program was rolled out there was minimal buy-in and a lot of push

back from staff. Many indicated frustration toward the new process and provided the top five

challenges in meeting the requirements: a) it became another ‘task’ that they are expected to
IMPLEMENTING A FALL PREVENTION PROGRAM 30

complete to the already long list of tasks they are required to complete per shift, b) ambulating a

patient and documenting activity is time consuming, c) most patients refuse to be mobilized, d)

implementing a new process at the same time as other processes are being implemented is very

challenging and burdensome, and e) acuity levels make it difficult to prioritize mobility.

Therefore, as of now, fully integrating this fall prevention program has not occurred and

still underway. Management has given the approval to move forward with implementing this

project and it is currently being trialed on 3S. However, the data analyzed indicates that only

45% of patients are being mobilized at this time. The goal is to be above 65% by the time this

project is fully integrated. Moreover, since trialing the fall prevention program, the M/S unit has

had a 7% reduction in falls. Although these results are primarily as the data presented only shows

information available to date and the findings indicate that current goals are well below the target

goal it is anticipated that the target goals will be reached. Furthermore, it is difficult to ascertain

if the reduction in falls is a direct result from trialing this fall prevention program or due to other

reasons. However, as the project is fully integrated and data is collected it will be easier to

determine the success of this project.

At this point, tt has been determined that current results are not at target goal because

staff is not performing BMAT assessments and assigning appropriate BMAT levels, is not using

the PMGP tool, is not using the BMAT magnets which are all imperative in the success of the

program. The plan is to reinforce education on the use of these tools in order to continue efforts

to reach the goal of a 25% reduction in falls by end of the year.

Summary Report

The fall prevention program aims to reduce falls in the M/S unit by 25% by December

2019. The implementation of this program began with identifying the cause and effect of patient
IMPLEMENTING A FALL PREVENTION PROGRAM 31

falls. Once it was identified that the lack of prioritizing mobility was a contributing factor to the

increase in falls this became the focus of the project. The CNL leader established a mobility/fall

task force team that worked closely to develop the program. This included using existing fall

prevention practices in place in addition to developing the PMGP tool to be used. The Kotter’s

eight-step change model was used as a guidance to enforce the desired change. However, there

was some resistance from staff in implementing this project. But, with reinforcement and by

applying Kotter’s change model along with the mobility tools there was a notable decrease in

falls. The culture change is beginning to show positive outcomes which indicates that this change

can be sustainable.

Conclusion

Sustaining this program will require the mobility/fall task force team to remain intact and

meet monthly to discuss ongoing progress of the program and to review data. The goal is to

monitoring data to determine the success and whether it has led to positive outcomes.

Furthermore, to ensure that the culture of prioritizing mobility remains a standard of practice, it

will require the unit champion to continue ongoing efforts of encouraging staff to prioritize

patient mobility and to continuously reinforce the need to perform and document accurate fall

and BMAT assessments and to implement appropriate mobility interventions using existing

practices in place.

This fall prevention program provides a cost-effective method that staff can effortlessly

implement and it has the potential to become a sustainable process that can eventually be a part

of the culture of safety within the M/S unit. There will be a cost benefit from a reduction in falls

because this will lead to reduced costs to treat any injuries and from a decrease in LOS. Further

this program will result in improved patient safety, increased patient satisfaction, and overall
IMPLEMENTING A FALL PREVENTION PROGRAM 32

improved quality of patient care. This proposed program provides feasible interventions that can

be used and implemented at a low-cost leading to positive results.

IMPLEMENTING A FALL PREVENTION PROGRAM 33

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IMPLEMENTING A FALL PREVENTION PROGRAM 37

Annotated Bibliography

Dykes, P. C., Adelman, J. S., Alfieri, L., Bogaisky, M., Carroll, D., Carter, E., … Spivack,

L. B. (2019). The Fall TIPS (Tailoring Interventions for Patient Safety) Program: A

Collaboration to End the Persistent Problem of Patient Falls. Nurse Leader, 17(4),

365–370.

The article describes how leaders in organization established an interdisciplinary team led

by nurses to develop an evidence-based fall prevention program known as Fall TIPS. The

authors indicate that the Fall TIPS program is currently used in various hospitals across the

country. According to the authors, this Fall TIPS study was the first randomized clinical

trial in the U.S. and it has demonstrated a significant reduction in patient falls in acute care

settings. This authors prose using the Fall TIPS program as a resource to support

implementation of a fall prevention program because it is found that a common barrier to

fall prevention is developing a new program rather than using evidence-based approaches.

Spano-Szekely, L., Winkler, A., Waters, C., Dealmeida, S., Brandt, K., Williamson, M., …

Wright, F. (2019). Individualized Fall Prevention Program in an Acute Care Setting:

An Evidence-Based Practice Improvement. Journal of Nursing Care Quality, 34(2),

127–132.

The article describes how the authors evaluated a hospital’s existing fall prevention

program using the evidence-based practice improvement model. The approach was to

analyze the clinical practice guidelines and interventions that included a nurse-driven

mobility assessment, purposeful hourly rounding, and video monitoring for confused and

impulsive fall-risk patients. According to the authors this fall prevention program was

established in a 245-bed community hospital. The authors indicate that this fall prevention
IMPLEMENTING A FALL PREVENTION PROGRAM 38

program led to a fall rate decreased to 1.14. Further, authors provide that there was a 72%

expense reduction in salary costs based on a decrease in a sitter use.

Walsh, C., Liang, L., Grogan, T., Coles, C., McNair, N., & Nuckols, T. (2018). Temporal

Trends in Fall Rates with the Implementation of a Multifaceted Fall Prevention

Program: Persistence Pays Off. The Joint Commission Journal on Quality and Patient

Safety, 44, 75-83.

The article reviewed the causes for a sustained reduction in fall rates since implementation

of a fall prevention program. The authors provided that the reasons for sustained reduction

in falls is because the program is well established since it was introduced in 2003. The

authors indicate that the success of this program is largely due to the incremental approach

of implementing changes over time. The authors provide that this leads to better positive

outcomes. The authors support that any hospital interested in implementing a successful

fall prevention program that is concern with overburdening frontline staff or with

competing financial priorities may find that introducing small changes is better approach

to attain the goals desired.

Zhao, Y., Bott, M., He, J., Kim, H., Park, S. H., & Dunton, N. (2019). Evidence on Fall and

Injurious Fall Prevention Interventions in Acute Care Hospitals. Journal of Nursing

Administration, 49(2), 86–92.

The authors discussed the factors associated with falls and falls with injuries. According to

the authors, evidence indicates that falls are a complicated phenomenon that involves

multiple factors, including intrinsic and extrinsic factors. The authors describe that

evidence supports an intrinsic factor that is often associated with advanced age is falls. The

extrinsic factors that are also found to be associated with falls are the hospital and unit
IMPLEMENTING A FALL PREVENTION PROGRAM 39

organization characteristics. The authors support the need to address these factors in order

to successfully implement a fall prevention program.

IMPLEMENTING A FALL PREVENTION PROGRAM 40

Appendix A

Inpatient Falls by Floors (To date)

APR 2S 2W 3S 4S Mean Total Total %­

Falls Falls in
(2019) (2018) falls
Jan-19 1 0 0 1 2 2 4 4
Feb-19 0 0 0 1 2 2 3 4
Mar-19 0 1 1 5 3 2 10 5
Apr-19 1 1 0 2 1 2 5 3
May-19 1 2 0 1 1 2 5 3
Jun-19 1 1 0 1 2 2 5 2
Jul-19 2 1 0 2 1 2 6 3
Aug-19 0 0 0 1 1 2 2 2
Sep-19 1 0 0 1 0 2 2 2
Oct-19 0 0 0 0 1 2 1 2
Nov-19 0 1 0 0 2 2 3 2
46 32 44%

Total Falls by Floor

5
Implementation
4 of fall prevention
program
3

0
19

19

9
19

9
19

-1
-1

-1
-1

-1

-1

-1
n-

b-

p-
n-
ar

ay
pr

ug

ct

ov
l
Ju
Fe

Se
Ja

Ju

O
M

APR 2S 2W 3S 4S Mean
IMPLEMENTING A FALL PREVENTION PROGRAM 41

Appendix B

Cause and Effect (Fishbone Diagram) of factors contributing to falls

Factors leading to
falls
IMPLEMENTING A FALL PREVENTION PROGRAM 42

Appendix C

Cause and Effect (Fishbone Diagram) of factors contributing to falls

Education Activity Orders

Low priority task
Inappropriate PT consult orders
No goals
Time management
Lack of communication
(between RN and CNA)

Mobility Issues
Unable to gather meaningful data
No goals Magnet signs
• BMAT
• PT consult Orders Activity
Not wanting to get up
BMAT utilization (correctly)
Admit orders (Lisa D)
Bed alarms
“Call Don’t Fall”
IMPLEMENTING A FALL PREVENTION PROGRAM 43

Appendix D

5 Point Process Mapping for using the BMAT to mobilize patient

IMPLEMENTING A FALL PREVENTION PROGRAM 44

Appendix E

Driver Diagram: A Conceptual Model of Process for Mobility

IMPLEMENTING A FALL PREVENTION PROGRAM 45

Appendix F

Clinical Staff Survey (Likert Five-Point Scale)

Subject: To determine top reasons patients are not mobilized

To: All Medical-Surgical Unit Staff

From: CNL and Fall Prevention Team

Situation: Increased patient falls in the M/S Unit

Background: It has been noted that this year there was been a rise in patient falls

on the M/S units in comparison to previous year.

Assessment: This year there have been 39 falls in the M/S unit

Recommendation/Action: To implement a fall prevention program by promoting mobility

The purpose of this survey is to identify the top reasons patients are not actively mobilized

during hospitalization. Your responses will assist in identifying the needs in the unit and will

assist us in developing a fall prevention program.

1. How often do you ambulate your patients?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

2. Do you educate your patients on the importance of mobilizing?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

3. Do you consider patient mobility to be a priority?

4. ¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

5. Do you feel that you have the necessary tools and resources necessary to mobilize
patients?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

6. How often are you performing the BMAT assessment on your patients?
IMPLEMENTING A FALL PREVENTION PROGRAM 46

7. ¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

8. Do you discuss the Fall Prevention Contract with patients and obtain consent?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

9. Do you feel that patient safety is an important aspect of care?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

10. How often do you use a bed/chair alarm?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

11. Do you perform purposeful hourly rounding on all your patients?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

12. Do you consider fall prevention to be a priority?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

13. Do you feel that management provides you with the support needed to prioritize
mobility?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

14. Do you make ambulating a patient your priority when providing care?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

15. Do you consider time constraints is the primary reason for not prioritizing mobility?

¨ Almost Always ¨ Often ¨ Sometimes ¨ Rarely ¨ Never

IMPLEMENTING A FALL PREVENTION PROGRAM 47

Appendix G

Staff Survey Response Results

How often do you ambulate your patient?

Response Response
Count Percent
Almost Always 18 15%
Often 16 13%
Sometimes 47 38%
Rarely 24 20%
Never 18 15%
123 100%

How often do you ambulate your

patient?

Never Almost Always

15% Almost Always
15% Often
Sometimes
Often
Rarely
Rarely 13%
19% Never

Sometimes
38%
IMPLEMENTING A FALL PREVENTION PROGRAM 48

Appendix H

Staff Survey Response Results

Do you consider patient mobility to be a priority?

Response Response
Count Percent
Almost Always 53 43%
Often 32 26%
Sometimes 25 20%
Rarely 10 8%
Never 3 2%
123 100%

Do you consider patient mobility to be a priority?

Never
Rarely
3%
8%
Almost Always
Sometimes Almost Always Often
20% 43%
Sometimes
Rarely
Never

Often
26%
IMPLEMENTING A FALL PREVENTION PROGRAM 49

Appendix I

Staff Survey Response Result

Do you make ambulating a patient your priority

when providing care?
Response Response
Count Percent
Almost
Always 12 10%
Often 18 15%
Sometimes 43 35%
Rarely 28 23%
Never 22 18%
123 100%

Do you make ambulating a patient your priority

when providing care?

Almost Always
10%
Never
18%
Often Almost Always
14%
Often
Sometimes
Rarely Rarely
23%
Never
Sometimes
35%
IMPLEMENTING A FALL PREVENTION PROGRAM 50

Appendix J

Staff Survey Response Result

Do you consider time constraints is the primary

reason for not prioritizing mobility?
Response Response
Count Percent
Almost
Always 73 59%
Often 28 23%
Sometimes 12 10%
Rarely 9 7%
Never 1 1%
123 100%

Do you consider time contraints is the primary

reason for not prioritizing mobility?

Rarely
7%
Never
1%
Sometimes
10%
Almost Always
Often
Sometimes
Often Almost Always Rarely
23% 59%
Never
IMPLEMENTING A FALL PREVENTION PROGRAM 51

Appendix K

Banner Mobility Assessment Tool

B.M.A.T. ‐ Banner Mobility Assessment Tool for Nurses

Fail =
Test Task Response Choose Most Appropriate Pass
Equipment/Device(s)
Assessment Sit and Shake: From a semi-reclined position, ask Sit: Patient is able to follow commands, MOBILITY LEVEL 1 Passed Assessment
Level 1 patient to sit upright and rotate* to a seated position at has some trunk strength; caregivers may Level 1 = Proceed with
Assessment of: the side of the bed; may use the bedrail. be able to try weight-bearing if patient is - Use total lift with sling and/or repositioning Assessment Level 2.
-Cognition able to maintain seated balance greater sheet and/or straps.
-Trunk strength Note patient’s ability to maintain bedside position. than two minutes (without caregiver - Use lateral transfer devices such as roll
-Seated balance assistance). board, friction reducing (slide sheets/tube),
Ask patient to reach out and grab your hand and shake or air assisted device.
making sure patient reaches across his/her midline. Shake: Patient has significant upper body
strength, awareness of body in space, and NOTE: If patient has ‘strict bed rest’ or
Note: Consider your patients cognitive ability, including grasp strength. bilateral ‘non-weight bearing’ restrictions,
orientation and CAM assessment if applicable. do not proceed with the assessment;
patient is MOBILITY LEVEL 1.
Assessment Stretch and Point: With patient in seated position Patient exhibits lower extremity stability, MOBILITY LEVEL 2 Passed Assessment
Level 2 at the side of the bed, have patient place both feet on strength and control. Level 2 = Proceed with
Assessment of : the floor (or stool) with knees no higher than hips. - Use total lift for patient unable to weight- Assessment Level 3.
-Lower extremity bear on at least one leg.
strength Ask patient to stretch one leg and straighten the knee,
- Use sit-to-stand lift for patient who can
-Stability then bend the ankle/flex and point the toes. If May test only one leg and proceed
weight-bear on at least one leg.
appropriate, repeat with the other leg. accordingly (e.g., stroke patient, patient
with ankle in cast).

Assessment Stand: Ask patient to elevate off the bed or chair Patient exhibits upper and lower extremity MOBILITY LEVEL 3 Passed Assessment Level
Level 3 (seated to standing) using an assistive device (cane, stability and strength. 3 AND no assistive
Assessment of: bedrail). - Use non-powered raising/stand aid; default device needed = Proceed
-Lower extremity May test with weight-bearing on only to powered sit-to-stand lift if no stand aid with Assessment Level 4.
strength for standing Patient should be able to raise buttocks off bed and one leg and proceed accordingly (e.g., available.
stroke patient, patient with ankle in - Use total lift with ambulation accessories.
hold for a count of five. May repeat once.
cast). - Use assistive device (cane, walker, Consult with
crutches).
Note: Consider your patients cognitive ability, including Physical Therapist when
orientation and CAM assessment if applicable. If any assistive device (cane, walker, NOTE: Patient passes Assessment Level 3 needed and appropriate.
crutches) is needed, patient is Mobility but requires assistive device to ambulate
Level 3. or cognitive assessment indicates poor
safety awareness; patient is MOBILITY
LEVEL 3.
Assessment Walk: Ask patient to march in place at bedside. Patient exhibits steady gait and good MOBILITY LEVEL 3 MOBILITY LEVEL 4
balance while marching, and when MODIFIED
Level 4 Then ask patient to advance step and return each foot.
stepping forwards and backwards.
Assessment of: If patient shows signs of unsteady gait or INDEPENDENCE
-Standing balance Patient should display stability while performing tasks. fails Assessment Level 4, refer back to Passed = No assistance
Patient can maneuver necessary turns for
-Gait Assess for stability and safety awareness. in-room mobility. MOBILITY LEVEL 3; patient is MOBILITY needed to ambulate; use
LEVEL 3. your best clinical judgment
Patient exhibits safety awareness. to determine need for
supervision during
ambulation.
Always default to the safest lifting/transfer method (e.g., total lift) if there is any doubt in the patient’s ability to perform the task.
Originated: 2011; revised: 2/27/12, 3/02/12, 3/07/12, 3/19/12, 4/19/12, 5/01/12, 5/03/12, 05/20/2013

Perez, 2015. Retrieved from https://www.uclahealth.org/nursing/workfiles/ContinuingEducation2015/TeachBack/UmoveBMAT-

TrainingPresentation.pdf
 IMPLEMENTING A FALL PREVENTION PROGRAM 52

Appendix L

Strengths, Weakness, Opportunities, and Threats (SWOT) Analysis

SWOT Analysis
•Hourly rounding
•Use of Morse Fall Score for fall risk assessment
•Use of bed and chair alarms
•Fall Contract
•Organizations desire to reduce falls
•Leadership support
Strenghts •Use of BMAT tool to assess mobility level
•Established standards and procedures for use of BMAT
•Staff understands the importance of moblizing patients

• Staff does not prioritize mobility

• Staff does not actively mobilize patients
• Staff does not educate patients about importance of mobility
• Staff does not properly do a BMAT assessment on all patients per
Weaknesses policy and procedures
• Staff does not use fall prevention agreement per policy and procedures

• Reduce fall rates

• Improving patient care outcomes
• Improving patient safety
• Improving patient satisfaction
Opportunities
• Increasing staff compliance for fall prevention practices

• Staff non-compliance with mobility plan

• Staff ability to effectively time manage
• Increased LOC from injuries due to falls sustained
Threats • Increased costs to treat injuries from falls sustained
 IMPLEMENTING A FALL PREVENTION PROGRAM 53

Appendix M

Kotter’s 8 Steps to Promote Change

Standardize the process

Develop a team comprised of
intellects, mediators, and Continue enforcing change
innovators to promote change Implement changes
• Intellects will focus on Make
gradually change
implementation of project Don't let
stick
• Mediators will be the up
Create
negotiators in getting buy in Empower short term
• Innovators will be wins
action/
visionaries Communicate remove
Get the buy in obsticles
Build the vision
right
guiding
Increase team
urgency
IMPLEMENTING A FALL PREVENTION PROGRAM 54

Appendix N

Plan-Do-Act-Study (PDSA) cycle for improvement process

• Identify goals and objectives

• Implement change to refine • Obtain feedback
the project
• Literature review
• Share recommendations
• Develop timeline
with management
• Create staff survey
• Begin the next phase
• Develop monitoring tools

Act Plan

Study Do

• Present findings to
• Analyze data management
• Compare data to expected • Implement plan
results • Perform audits
• Summarize findings • Collect and monitor data
• Provide support
 IMPLEMENTING A FALL PREVENTION PROGRAM 55

Appendix O

Plan-Do-Act-Study (PDSA) continuous cycle for improvement process

PDSA Cycle for Testing and Adaptation a Continuous Improvement Process

PDSA Cycle 1:
PDSA Cycle 4: • Establish the
• Collect and monitor data Act Plan multidisciplinary team
• Analyze data • Assign team member roles
• Compare data to expected results and responsibilities
• Summarize findings • Identify goals and objectives
• Present findings to management Study Do
• Share recommendations to management
• Continue standardizing process
• Begin next phase

Continuous
Improvement
Act Plan Act Plan

Study Do Study Do

Quality Improvement
Standardization of
process
PDSA Cycle 3:
PDSA Cycle 2:
• Develop timeline
• Develop a survey using a
• Develop monitoring tools to audit Likert 5-point scale
progress Act Plan
• Conduct survey to obtain
• Develop the tools and resources to be feedback
provided to staff
• Review results and
• Educate staff on the fall prevention develop plan
program Study Do
• Implement program

Time
IMPLEMENTING A FALL PREVENTION PROGRAM 56

Appendix P

Patient Mobility Goal Plan Tool (front and back)

Patient Mobility Goal Plan

DATE: DATE: DATE: DATE:
Level 4
Walk
Possibly High Fall Risk
Independent
Equipment: not required; reassess
as needed AM PM NOC AM PM NOC AM PM NOC AM PM NOC
• Walk in the hall
• Walk around the unit Indicate time in the box Indicate time in the box Indicate time in the box Indicate time in the box

`
Level 3
Stand
High Fall Risk
Minimum Assistance
Equipment: Sit-to-stand device,
ambulation aid
• Up in chair w/min assist AM PM NOC AM PM NOC AM PM NOC AM PM NOC
• Stand w/assist Indicate time in the box Indicate time in the box Indicate time in the box Indicate time in the box
• Ambulate w/walker in hall/unit
Level 2
Chairfast
High Fall Risk
Moderate Assistance
Equipment: Mechanical lift, sling,
or sit-to-stand device
• Dangle
AM PM NOC AM PM NOC AM PM NOC AM PM NOC
• Up in chair w/assist (if dialysis
sit for a min of 3 hours) Indicate time in the box Indicate time in the box Indicate time in the box Indicate time in the box
• In bed strengthening
Level 1
Bedfast/Dependent
High Fall Risk
Maximum Assistance Required
Equipment: 2-Person assist
using mechanical lift, sling,
and/or safe handling sheet
AM PM NOC AM PM NOC AM PM NOC AM PM NOC
• Range of motion exercises
Indicate time in the box Indicate time in the box Indicate time in the box Indicate time in the box
• Chair-position in bed

Why is mobility important?

Did you know?
Most importantly, you get to go home sooner!
Prolonged bed rest can lead to……
What should you do?
• Increased risk for hospital acquired complications such as:
o DVT • Become an active participant in your care
o Falls • Partner with your care team to develop your mobility goal plan during
o Hospital acquired pneumonia your hospital stay
o Deconditioning and functional decline from baseline • Your ultimate goal is to maintain or reach your functional baseline
§ Leads to weakness due to loss of muscle strength o By ambulating or performing an activity at least three times a
• Increased hospital length of stay day to reach your goal
• Increased risk of discharging to a nursing home vs home • Take action and collaborate with our care team to reach your daily
goals
Mobility is important because it…. o If you haven’t reached your goal for the day, request for
assistance to ensure you get your activity in
• Improves your overall strength and endurance o Don’t forget to document each time you have accomplished your
• Promotes early oxygen weaning goal
• Decreases your risk for fall
• Leads to a faster recovery We encourage you to get up and move!

References

Brown CJ, Friedkin RJ, & Inouye SK. (2004). Prevalence and outcomes of low mobility in hospitalized older patients. Journal of the American Geriatrics Society, 52(8), 1263–1270. https://doi.org/10.1111/j.1532-5415.2004.52354.x

Hoyer EH, Friedman M, Lavezza A, Wagner-Kosmakos K, Lewis-Cherry R, Skolnik JL,…Needham DM. (2016). Promoting mobility and reducing LOS. Journal of Hospital Medicine, 11(5(, 341-347. doi:10.1002/jhm.254
IMPLEMENTING A FALL PREVENTION PROGRAM 57

Appendix Q

Tool to Measure Outcomes and Prevention Practices

Outcomes Measures
Key Indicator Measure Definitions Data Collection Target Goal
Source
Fall rates (falls per 1,000 # of patient falls per Fall incident reports 25% and above
occupied bed days) day in the unit reduction
Monthly average % of % of patients Audit of Cerner 65% and above
patient ambulation ambulated per day
Monthly average length The average length of Quality Department £ 4 days
of stay (LOS) in the M/S stay of patients in the
units unit per month
Process Measures
Key Indicator Measure Definitions Data Collection Target Goal
Source
Fall risk assessment N = # of fall risk Audit of Cerner 100%
using the Morse Fall assessments
Scale is accurately documented
performed within 12 D = # of patients
hours of admission assigned
BMAT level assessment N = # of BMAT Audit of Cerner 100%
is accurately performed assessments
within 12 hours of documented
admission D = # of patients
assigned
Patient Mobility Goal N = # of patient Visual audit of 75% and above
Plan tool is used to mobility goal plans mobility goal plans
develop the mobility plan documented completed
D = # of patients
assigned
Use of BMAT magnets N = # of patient Visual audit of 85% and above
mobility goal plans BMAT magnets
documented completed
D = # of patients
assigned
Balancing Measure
Key Indicator Measure Definitions Data Collection Target Goal
Source
# of falls per month by # of falls per day in Fall incident reports £2
December 2019 the unit
# of falls per month by # of falls per day in Fall incident reports 0
December 2020 the unit
IMPLEMENTING A FALL PREVENTION PROGRAM 58

Appendix R

Tool to Measure Outcomes and Prevention Practices

Outcomes Measures
Key Indicator Measure Definitions Data Collection Target Results
Source Goal
Fall rates (falls per # of patient falls per Fall incident 25% and 7%
1,000 occupied bed day in the unit reports above
days) reduction
Monthly average % of % of patients Audit of Cerner 65% and 45%
patient ambulation ambulated per day above
Monthly average length The average length Quality £ 4 days 3.75
of stay (LOS) in the of stay of patients in Department days
M/S units the unit per month
Process Measures
Key Indicator Measure Definitions Data Collection Target Results
Source Goal
Fall risk assessment N = # of fall risk Audit of Cerner 100% 100%
using the Morse Fall assessments
Scale is accurately documented
performed within 12 D = # of patients
hours of admission assigned
BMAT level N = # of BMAT Audit of Cerner 100% 86%
assessment is assessments
accurately performed documented
within 12 hours of D = # of patients
admission assigned
Patient Mobility Goal N = # of patient Visual audit of 75% and 10%
Plan tool is used to mobility goal plans mobility goal above
develop the mobility documented plans completed
plan D = # of patients
assigned
Use of BMAT magnets N = # of patient Visual audit of 85% and 65%
mobility goal plans BMAT magnets above
documented completed
D = # of patients
assigned
Balancing Measure
Key Indicator Measure Definitions Data Collection Target Results
Source Goal
# of falls per month by # of falls per day in Fall incident £2 Not
December 2019 the unit reports available
# of falls per month by # of falls per day in Fall incident 0 Not
December 2020 the unit reports available
 IMPLEMENTING A FALL PREVENTION PROGRAM 59

Appendix S

Estimated costs for Material and Labor for the First and Second Years

Estimated Costs for Material and Labor for the First Year and Second Years
Materials and Labor First Year Materials and Labor Second
Costs Year Costs
RN Educator - Provide $56 /hr x 3 hr $ 1,680.00 RN Educator - $56 /hr x 3 hr $ 1,680.00
Training x 10 days Provide Retraining x 10 days
PT - Provide Training $68 / hr x 3 hr $ 2,040.00 PT - Provide $68 / hr x 3 hr $ 2,040.00
x 10 days Retraining x 10 days
120 RNs - Participating $52 /hr x 3 hr $ 18,720.00 120 RNs - $52 /hr x 3 hr $ 18,720.00
in Training x 120 staff Participating in x 120 staff
Retraining
50 CNAs - Participating $17 / hr x 3 hr $ 2,550.00 50 CNAs - $17 / hr x 3 hr $ 2,550.00
in Training x 50 staff Participating in x 50 staff
Retraining
Consultant Fee $150 / session $ 1,500.00 Consultant Fee $150 / session N/A
x 10 days x 10 days

Paper - to print agendas, 5 boxes x $26 $ 130.00 Paper - to print 5 boxes x $26 $ 130.00
educational brochures, each agendas, educational each
and powerpoint brochures, and
presentation powerpoint
presentation
Printer / Computer $ 480.00 Printer / Computer $ 480.00
Equipment (Patient safety gait belts $18 $ 20,740.00 Equipment (Patient N/A
supplies) - gait belts, each /110 total safety supplies) - gait
walker, lifts rooms, belt, walker, lifts
walkers $46
each / 60 total,
mechanical
lifts $3,200
each / 5 total

Total Project Cost $ 47,840.00 Total Project Cost $ 25,600.00

 IMPLEMENTING A FALL PREVENTION PROGRAM 60

Appendix T

Cost Benefit Analysis (CBA)

Cost Benfit Analysis (CBA)

Number of reported falls Estimated Costs based
Costs & Benefits Average Cost Per Fall* (42) on the unit as of on number of reported
October 2019 falls (30) to date
Costs $ 14,000 42 $ 588,000

To Staff/Unit/Hospital To Patients
A 25% reduction in falls Timely discharge (reduced $ 147,000
by December 2019 LOS)
A 50% reduction in falls Improved patient safety $ 294,000
by December 2020
Cost savings in reduced
Benefits (Savings)
LOS
Decrease in falls leads to
more bed occupancies for
admissions
Cost savings from
potential lawsuits
Projected Cost Savings Year 1 $147,000

Projected Cost Savings Year 2 $294,000

Total Project Cost Year 1 $57,000

Total Project Cost Year 2 $33,000

Total Cost Savings in 1 Year (cost savings minus project cost) $90,000

Total Cost Savings in 2 Year (cost savings minus project cost) $261,000

*Note: Based on estimated costs to treat falls from The Joint Commission (2016).
 IMPLEMENTING A FALL PREVENTION PROGRAM 61

Appendix U

Gantt Chart

Proposed Timeline (Gantt Chart)

Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20
Team & CNL to create and
conduct Likert survey to
determine barriers preventing
mobility
Team & CNL to develop and
implement patient mobility
program
Team & CNL to develop a staff
training educational plan
Team & CNL to enforce the use
of patient fall agreement
Team to prepare an agenda for
training session
Team & CNL to collaborate with
RN educator to teach mobility
program
M/S Staff Training to attend 3
hour training
Implemention of Mobility
Program
CNL develops the Patient
Mobility Goal Plan tool,
educates staff on use, and
implements use
Patients receive education about
mobility program and receive
educational pamphlet about fall
prevention. (Expected)
Team & CNL monitors staff to
eveluate effectiveness of
education and mobility program
Team & CNL gathers and
monitors data to evaluate
progress from inception of
program until Dec-19.
Team & CNL the M/S unit fall
report and compares fall rates
from Aug-19-Dec-19.
Staff to attend a 1 hour training
(to reinforce education)
Patients sign fall contact
agreement
Team & CNL obtains data to
compare fall rates from Aug-19
to Dec-20.
Team & CNL evaluates
effectives of fall prevention
program/updates MS unit on
project status
IMPLEMENTING A FALL PREVENTION PROGRAM 62

Appendix V
Staff Training Agenda
Date: August-19
Topic: Promoting Patient Mobility
Location: Learning Resource Center, West Campus Room A & B
Educators: M/S Educator & CNL

Time Topic Description Educator

9-9:15 AM Falls Define falls, discuss rates of fall RN Educator
occurrences per year and costs associated and CNL
with falls, causes, risks associated with
falls, followed by Q&A.
9:15-9:45 AM Mobility What is mobilty, why is it important, RN Educator
assessing patients' functional mobility level, and CNL
collaborating with team to ambulate patients,
indentifying barriers preventing mobility,
provide tools and strategies, educate on the
moblity program and tools to be used,
followed by Q&A.
9:45-10:15 AM Techniques Review proper techniques to mobilize PT
and Proper patients, demonstrate proper body
Body mechanics to prevent harm to patients and
Mechanics staff, discuss how to determine the proper
equipment to use to mobilize patient,
followed by Q&A.
10:15-10:45 AM Equipment Demonstrate how to properly use Consultant
equipment, followed by Q&A.
10:45-11:30 AM Evidence- Recommed EBP to promote mobility, RN Educator
Based assessing patient for mental or physiological and CNL
Practices changes, reviewing medications and need
for precautions with use of medications,
maintaining contience (hourly rounding),
and implementing mobiity plan, followed by
Q&A.
11:30 -12:00 PM Apply Staff to break into two groups (5 RNs and 5 RN Educator
Education CNs). One group will demonstrate to class and CNL
how to perform a functional mobility level
assessment and show how to mobilize
patient using tools and techniques provided.
Each group will have an opportunity to
demontrate to class.
IMPLEMENTING A FALL PREVENTION PROGRAM 63

Appendix W

Promoting Patient Mobility Educational Plan

Attention: RN’s and CNA’s in the M/S Unit

Topic: Promoting Patient Mobility
Location: Learning Resource Center
Educators: M/S Educator & Clinical Nurse Leader (CNL)

1. Trainees: All RNs and CNA’s working in the M/S Unit

2. Educational Level: RNs and CNA’s including nursing students that provide patient care.
3. Socio-economic Level: Charge nurses, managers, and therapists can participate.
4. Cultural aspects to be considered: A culture of safety will be changing as all staff will be
expected to actively mobilize patients. Families members will be asked to actively participate as
well. Patient will be encouraged to ask to be mobilized. This mobility plan will improve the
quality of patient care and promote patient safety.
5. Developmental Level: Staff will receive training to acquire the knowledge and skills needed to
promote patient mobility. Learning will occur through listening, observing, participating, and
demonstrating that they have understood the education provided to certify competency and
completing of training.
In the M/S unit there is no existing mobility program in place. The purpose of this
educational plan is to emphasize the need for a mobility program and develop a plan that can be
utilized by the M/S staff. Recommendations will be based on evidence-based practices and those
established by the AHRQ.
Teaching Objectives
At the end of the class, participants will be able to:
1. Define falls and causes for falls.
2. Describe the recommended best practices to promote mobility.
3. Demonstrate proper assessment of functional mobility status and develop a plan to
mobilize patient by using the proper tools and technique learned.
4. Completing of training and acceptance of practice will be certified by signing an
acknowledgment form indicating that education and training were received.
IMPLEMENTING A FALL PREVENTION PROGRAM 64

Appendix X

Staff Training Acknowledgement Form

Training Topic: Promoting Patient Mobility

Date of Attendance: Insert Date

I confirm that I attended the training class referenced above on this date. I acknowledge

that I listened, read, and understood the training on the Fall Prevention Program by

demonstrating how to properly assess, educate, and mobilize patients. I understand that as an

employee of this organization, it is my responsibility to utilize the knowledge and skills acquired

while providing patient care and agree to abide by the organizations policy and procedures, in

accordance with the training. If understand that if I have any questions about the training

received, materials presented or the organizations policy and procedures, it is my responsibility

to seek clarification.

Employee Name:

Employee Signature:

Position:

Department: Medical and Surgical Unit

IMPLEMENTING A FALL PREVENTION PROGRAM 65

Appendix Y

IRB Non-Research Determination Table

EVIDENCE-BASED CHANGE OF PRACTICE PROJECT CHECKLIST *

STUDENT NAME: Araiza, Alba
DATE: August 19, 2019
SUPERVISING FACULTY: Robin Jackson
Instructions: Answer YES or NO to each of the following statements:
Project Title: YES NO

The aim of the project is to improve the process or delivery of care with X
established/ accepted standards, or to implement evidence-based change. There is
no intention of using the data for research purposes.
The specific aim is to improve performance on a specific service or program and is X
a part of usual care. ALL participants will receive standard of care.
The project is NOT designed to follow a research design, e.g., hypothesis testing X
or group comparison, randomization, control groups, prospective comparison
groups, cross-sectional, case control). The project does NOT follow a protocol that
overrides clinical decision-making.
The project involves implementation of established and tested quality standards X
and/or systematic monitoring, assessment or evaluation of the organization to
ensure that existing quality standards are being met. The project does NOT
develop paradigms or untested methods or new untested standards.
The project involves implementation of care practices and interventions that are X
consensus-based or evidence-based. The project does NOT seek to test an
intervention that is beyond current science and experience.
The project is conducted by staff where the project will take place and involves X
staff who are working at an agency that has an agreement with USF SONHP.
The project has NO funding from federal agencies or research-focused X
organizations and is not receiving funding for implementation research.
The agency or clinical practice unit agrees that this is a project that will be X
implemented to improve the process or delivery of care, i.e., not a personal
research project that is dependent upon the voluntary participation of colleagues,
students and/ or patients.
If there is an intent to, or possibility of publishing your work, you and supervising X
faculty and the agency oversight committee are comfortable with the following
statement in your methods section: “This project was undertaken as an Evidence-
based change of practice project at X hospital or agency and as such was not
formally supervised by the Institutional Review Board.”
ANSWER KEY: If the answer to ALL of these items is yes, the project can be considered an
Evidence-based activity that does NOT meet the definition of research. IRB review is not required.
Keep a copy of this checklist in your files. If the answer to ANY of these questions is NO, you must
submit for IRB approval.
*Adapted with permission of Elizabeth L. Hohmann, MD, Director and Chair, Partners Human Research Committee,
Partners Health System, Boston, MA.
IMPLEMENTING A FALL PREVENTION PROGRAM 66

Appendix Z

Fall Prevention Program Poster Presentation

Implementing a Fall Prevention Program on a Medical-Surgical Unit

Alba Araiza, RN, MSN Graduate Student

How we will know there is What changes can we make Results

What we are trying to accomplish List Changes: Tool to Measure Outcomes and Prevention Practices
Project Aim: The aim is to reduce inpatient falls Measures: improvement
§ Design a patient mobility goal tool Outcomes Measures
Tool to Measure Outcomes and Prevention Practices Key Indicator Measure Definitions Data Collection Target Results
by 25% in the medical-surgical (M/S) unit by § Educating staff and implementing use of tool Source Goal
Outcomes Measures Fall rates (falls per # of patient falls per Fall incident 25% and 7%
December 2019 by providing necessary tools and Key Indicator Measure Definitions Data Collection Target Goal § Collect data and analyze success of tool 1,000 occupied bed day in the unit reports above
days) reduction
Source § Create a culture shift focusing on making mobility
resources to staff to prioritize mobility and Fall rates (falls per 1,000 # of patient falls per Fall incident reports 25% and above Monthly average % of % of patients Audit of the 65% and 45%
occupied bed days) day in the unit reduction a priority in patient care patient ambulation ambulated per day electronic health above
addressing barriers such as knowledge deficit. Monthly average % of % of patients Audit of the 65% and above
Kotter’s 8 Steps to Promote Change
Develop a team comprised of
intellects, mediators, and Standardize the process Monthly average length The average length of
record
Quality £ 4 days 3.75 days
patient ambulation ambulated per day electronic health innovators to promote change of stay (LOS) in the stay of patients in the Department
• Intellects will focus on Continue enforcing change
record
Global Aim: We aim to reduce inpatient falls in Monthly average length The average length of Quality Department £ 4 days
implementation of project
• Mediators will be the
Implement changes
M/S units unit per month
Process Measures
gradually Make
the M/S unit through implementation of a nurse- of stay (LOS) in the M/S
units
stay of patients in the
unit per month
negotiators in getting buy
in
• Innovators will be Create
Don't let
up
change
stick
Key Indicator Measure Definitions Data Collection
Source
Target
Goal
Results

Fall risk assessment N = # of fall risk Audit of the 100% 100%

driven fall prevention program to improve the Key Indicator
Process Measures
Measure Definitions Data Collection Target Goal
visionaries Empower
Communicate action/
buy in remove
short
term
wins
using the Morse Fall assessments electronic health
Scale is accurately documented record
quality and frequency of patient ambulation thus Source
Build
Get the
vision
obsticles
performed within 12 D = # of patients
Fall risk assessment N = # of fall risk Audit of the 100% PDSA Cycles Increase the right hours of admission and assigned
decreasing falls, decreasing hospital stay and using the Morse Fall
Scale is accurately
assessments
documented
electronic health
record
urgency guiding
team throughout stay.
BMAT assessment is N = # of BMAT Audit of the 100% 86%
PDSA Cycle for Testing and Adaptation a Continuous Improvement Process
readmissions, and increasing patient safety and performed within 12 D = # of patients PDSA Cycle 4: PDSA Cycle 1:
accurately performed
and BMAT level
assessments
documented
electronic health
record
hours of admission and assigned • Collect and monitor data • Establish the
satisfaction. throughout stay. • Analyze data multidisciplinary
assigned within 12 D = # of patients
hours of admission and assigned
BMAT assessment is N = # of BMAT Audit of the 100% • Compare data to expected team
Background: accurately performed and assessments electronic health results
• Summarize findings
Act Plan • Assign team member
roles and
throughout stay.
Patient Mobility Goal N = # of patient Audit of the 75% and 10%
BMAT level assigned documented record responsibilities Plan tool is used to mobility goal plans electronic health above
• Present findings to management
According to the The Joint Commission (2016) within 12 hours of
admission and
D = # of patients
assigned
• Share recommendations to
management
Study Do • Identify goals and
objectives
develop the mobility
plan
documented
D = # of patients
record and visual
audit of mobility
inpatient falls are preventable incidences, but are throughout stay.
Patient Mobility Goal N = # of patient Audit of EHR and 75% and above
• Continue standardizing process
• Begin next phase
assigned goal plans
completed
Continuous
one of the top reported sentinel events occurring in Plan tool is used to
develop the mobility plan
mobility goal plans
documented
visual audit of
mobility goal plans
after 1 month of
implementation Act Plan
Improvement
Act Plan
Use of BMAT magnets N = # of patient
mobility goal plans
Visual audit of
BMAT magnets
85% and
above
65%

documented completed
hospitals and are considered a serious problem D = # of patients
assigned
completed D = # of patients
Study Do Study Do assigned
because it compromises patient safety. According to

Quality Improvement
Use of BMAT magnets N = # of patient Visual audit of 85% and above Standardization of Balancing Measure
mobility levels BMAT magnets process Key Indicator Measure Definitions Data Collection Target Results
Walsh et al. (2018) and Zhao et al. (2019) in the documented completed
PDSA Cycle 3:
• Develop timeline PDSA Cycle 2: Source Goal
D = # of patients • Develop monitoring tools to • Develop a survey # of falls per month by # of falls per day in Fall incident £2 Not
U.S. the average fall rate of adults in a medical and assigned audit progress
• Develop the tools and
Act Plan using a Likert 5-
point scale
December 2019 the unit
# of falls per month by # of falls per day in
reports
Fall incident £1
available
Not
Balancing Measure
surgical (M/S) unit is 3-5 falls per 1,000 patient bed Key Indicator Measure Definitions Data Collection Target Goal
resources to be provided to
staff Study Do
• Conduct survey to
obtain feedback
December 2020 the unit reports available

days. Source • Educate staff on the fall • Review results and References
# of falls per month by # of falls per day in Fall incident reports £2 prevention program develop plan
December 2019 the unit • Implement program The Joint Commission (TJC). (2016). Preventing patient falls: A
Time
In the M/S unit, findings indicate a 44% increase in # of falls per month by
December 2020
# of falls per day in
the unit
Fall incident reports £1 Preliminary Results systematic approach from the Joint Commission center for
Outcome Measures: transforming healthcare project. Chicago, IL: Health Research and
falls occurring this year in comparison to the Tools: Patient Mobility Goal Plan
Educational Trust. Retrieved from http://www.hpoe.org/Reports-
DATE: DATE: DATE: DATE: § Fall rates have decreased by 7% from August 2019 to
previous year. Thus, the proposed plan is to Level 4
Walk
Possibly High Fall Risk October 2019 since inception of program HPOE/2016/preventing-patient-falls.pdf
implement a fall prevention program that is centered Walsh, C., Liang, L., Grogan, T., Coles, C., McNair, N., &
Independent
Equipment: not required; reassess
as needed
• Walk in the hall
AM PM NOC AM PM NOC AM PM NOC AM PM NOC § Monthly average of patients mobilized is at 45%, which is
• Walk around the unit Indicate time in the box Indicate time in the box Indicate time in the box Indicate time in the box

below the target goal of 65%. Nuckols, T. (2018). Temporal Trends in Fall Rates with the
around prioritizing patient mobility to assist in `
Level 3
Stand
High Fall Risk
§ On average, monthly LOS has decreased to 3.75 days, which Implementation of a Multifaceted Fall Prevention Program:
decreasing patient falls.
Minimum Assistance
Equipment: Sit-to-stand device,
ambulation aid
• Up in chair w/min assist
• Stand w/assist
AM PM
Indicate time in the box
NOC AM PM
Indicate time in the box
NOC AM PM
Indicate time in the box
NOC AM PM
Indicate time in the box
NOC
above the target goal. Persistence Pays Off. The Joint Commission Journal on Quality
and Patient Safety, 44, 75-83.
• Ambulate w/walker in hall/unit
Level 2
Process Measures:
Concentrating on patient mobility is the primary Chairfast
High Fall Risk
Moderate Assistance
Equipment: Mechanical lift, sling, § Data indicates 100% of staff is documenting fall risk https://doi.org/10.1016/j.jcjq.2017.08.009
focus as it has been found that it currently is not a
or sit-to-stand device
• Dangle
• Up in chair w/assist (if dialysis
sit for a min of 3 hours)
AM PM
Indicate time in the box
NOC AM PM
Indicate time in the box
NOC AM PM
Indicate time in the box
NOC AM PM
Indicate time in the box
NOC
assessments, which is at target goal. Zhao, Y., Bott, M., He, J., Kim, H., Park, S. H., & Dunton, N.
priority in the M/S unit. The intent of this program
• In bed strengthening
Level 1 § Data indicates 85% of staff is documenting a BMAT (2019). Evidence on Fall and Injurious Fall Prevention
Bedfast/Dependent
High Fall Risk
assessment, which is below target goal of 100%. Interventions in Acute Care Hospitals. Journal of Nursing
is to create a culture shift that focuses on prioritizing Maximum Assistance Required
Equipment: 2-Person assist
using mechanical lift, sling,
and/or safe handling sheet
§ Data indicates that 10% of staff is using the Patient Mobility Administration, 49(2), 86–92.
AM PM NOC AM PM NOC AM PM NOC AM PM NOC

mobility. • Range of motion exercises

• Chair-position in bed
Indicate time in the box Indicate time in the box Indicate time in the box Indicate time in the box

Goal Plan tool, which is an expected finding at this time. https://doi.org/10.1097/NNA.0000000000000715