1. Are you ready for this change?
Falls represent a considerable problem in hospitals. Efforts
to improve fall prevention require a system approach that achieves
organizational change through multiple, simultaneous modifications to workflow,
communication, and decisionmaking. This type of organizational change can be
difficult to achieve. Failure to assess your organization's readiness for
change can lead to unanticipated difficulties in implementation, or even the
complete failure of the effort.
Each question below will help you and your organization
explore readiness and identify any needed actions to improve it:
Do organizational members understand why change is needed?
Is there urgency to change?
Does senior leadership support this initiative?
Who will take ownership of this effort?
- What kinds of resources are needed?
What if you are not ready for full-scale change?
Organizational Readiness for Change: Locally Relevant
Even hospitals whose leaders are ready to support change
may face barriers to further progress. For example, senior leadership may believe
that effective fall prevention is essential and may demonstrate that fall
prevention is a high priority. However:
section of guide addresses these types of issues.
Some hospitals may experience significant turnover in senior
leadership and nursing leadership.
Competing patient safety and quality priorities may affect
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1.1. Do organizational members understand why
change is needed?
Knowing how care should be delivered is only one step in the
process of improving fall prevention. Readiness requires both the capability to
make changes and the motivation to change. That motivation may be helped along
by external factors, such as Federal or State mandates. But the motivation is
most likely to be strong and enduring if based on a clear understanding of the
concerns behind the planned change at all levels of the organization.
One of way of finding out whether people within your
hospital understand why change is needed is to perform a survey. Consider
administering a general survey, such as the AHRQ Hospital Survey on Patient
Safety Culture (Tool 1A, "Hospital Survey on
Patient Safety Culture") to assess the culture of safety in your hospital.
There are many potential reasons to implement a fall
prevention program. While we offer general reasons and statistics in the box
below, local reasons or cases may be more tangible and compelling. For example:
Has your facility experienced a significant increase in fall
Have there been any adverse events that were fall related?
Has your facility been the target of a legal action related to a
Do staff members have personal experience of a family member affected
by a fall?
Did you know?
Falls are common: Falls are the most frequently reported incident
in adult inpatient units. The rate of falls ranges from 1.7 to 25 falls per 1,000
patient days (see sections 5.1.3 to 5.1.5 for an explanation of rates), depending
on the unit, with geriatric psychiatry patients having the highest risk.a
There is a business case for fall prevention: Falls are
associated with increased length of stay, higher rates of discharge to nursing
homes, and greater health care utilization.b
One study found that operational costs for fallers with serious injury were
$13,316 higher than nonfallers.c As of 2008, Medicare no longer
reimburses hospitals for increased costs due to injury from an inpatient fall.d
Falls harm our patients: Thirty to 51 percent of falls in
hospitals result in some injury,b varying from bruises to severe
wounds or bone fractures.
Lasting improvement is more likely to occur if the various
people influencing fall prevention have a shared set of knowledge and
motivations. Those initiating interventions to prevent falls may clearly
understand the needed changes. However, knowledge and motivation to change may
vary greatly across the organization. Others in your hospital may have
different reasons for wanting change, so it is important to define the issues
and reasons for change in advance. This process will help make the case for why
a fall prevention initiative is needed now.
Updating knowledge and changing attitudes require both
sharing new information and dealing with existing knowledge and attitudes that
may undermine change efforts if left unaddressed. Be sure to assess the
knowledge and attitudes of all types of staff members involved in clinical
care, since awareness of the importance of fall prevention is an
Consider administering a survey to assess the culture of safety
in your hospital. The AHRQ Hospital Survey on Patient Safety Culture examines
patient safety culture from a hospital staff perspective. This survey can be
found in Tools and Resources (Tool 1A, "Hospital
Survey on Patient Safety Culture"). The results of the survey can be used
to identify areas for improvement in your hospital's culture.
Develop consensus on reasons a fall prevention program
needs to go forward. Developing consensus involves multiple steps:
Identify the reasons for having a fall prevention program in
your organization. If the reasons are general and not specific to your
hospital, try to find cases or examples that help bring the issue home to
Determine your facility leadership's interests and needs in
this area, and assess how much effort will be needed to obtain and sustain
Talk with other people (from various levels, roles, and
clinical areas) who support implementing a fall prevention program. This
group may include as many as 10 or 20 people who have a stake in this issue.
Based on this input, begin to clarify the shared reasons
Assess the extent to which organizational members beyond
potential supporters understand why a comprehensive fall prevention program
is important. This step can be completed in a variety of ways, such as small
group meetings, surveys, or a review of quality concerns raised by
Consider identifying one unit where the problem with falls is
worst or where staff are most enthusiastic about fall reduction. These staff
are most likely to understand why change is needed, so find out what they
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1.2. Is there urgency to
Beyond understanding why change is needed to improve fall
prevention, do organizational members find the need compelling? If a sense of
urgency does not yet exist among key organizational leaders and members, your
job as change agents is to increase or create it. At this early stage, the
focus is on urgency at the organizational level. Awareness and knowledge for
change at the unit level will be discussed in section
Consider the aspects of the problem that will be most
compelling to your stakeholders. Are there different aspects that are relevant
and persuasive for different audiences within the hospital? For example, for
some audiences, a business case for reducing falls may be more compelling; for
others, the clinical benefits may be more relevant.
In considering your arguments, you will need to evaluate
current organizational attention to falls. For example, who has lead
responsibility for fall prevention? Are fall rates regularly documented and
reported? If so, who receives and acts on the reports? Answers to these
questions will influence the way you make your case for improving fall
If your facility staff do not understand why improving fall
prevention is important, your task of increasing urgency will be more difficult.
Mounting an effective improvement effort will likely require greater support
from leadership, as discussed in section 1.3,
and more resources, as described in section 1.5.
Based on your current understanding of the situation, begin
to explore topics or themes that can be used to increase awareness and urgency. Consider framing your efforts
in line with broader initiatives, such as the Institute for Healthcare
Improvement Triple Aim (www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx ).
Reach out beyond those who already support efforts to
strengthen fall prevention. Begin talking with additional colleagues about fall
prevention and why it is important at your health care organization.
Listen to their responses to gather important information about
barriers of awareness and understanding that you may need to address later
Conduct a stakeholder analysis to identify key people and
departments that may have a stake in the success of this program.
||A template for stakeholder analysis can be found in Tools
and Resources (Tool 1B, "Stakeholder
the introductory slide
presentation developed by ECRI Institute. [PowerPoint® file, 240 KB; Plugin Software Help]
ECRI Institute should be cited as the source.
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1.3. Does senior administrative leadership support
You will need to ensure that your organization's leadership
team (i.e., top-level administration, medical staff leadership, and board of trustees)
shares the urgency to change fall prevention practices and is willing and able to
provide complete and ongoing support for this effort. Lessons learned from key
fall prevention initiatives show that support is needed from both the top-level
administration as well as those at the bedside.
To make your case most effectively to leadership, ask
yourself how support for a fall prevention program fits with other
institutional values and commitments. While you may not know at the outset all
the kinds of support that will be needed, you know that changes are going to
require new or reallocated resources, most likely both human and material. The
changes will also require focus and accountability for results, which will also
need senior leadership oversight.
If senior leaders do not already strongly support the effort
to strengthen fall prevention, you will need to build the case for change. For
some stakeholders, such as your chief financial officer, the most compelling
case may be a business case. You may discuss how much falls cost hospitals each
year in terms of longer lengths of stay, additional staff time, and reduced
reimbursement because Medicare no longer pays for preventable complications
from falls. For other stakeholders, such as clinical chiefs and nurse
executives, it may be a clinical case discussing how falls increase pain,
functional impairment, morbidity, and mortality.
Many hospitals have a strong emphasis on quality
improvement, with an improvement infrastructure in place. Consider contacting quality
improvement leaders in your organization for guidance and possible assistance
in enlisting leadership support. Also, you may want to enlist quality
improvement advisors to participate on your Implementation Team as described in
To assess leadership support and other questions raised
here, consider using a facility-level assessment similar to Tool 1C, "Leadership Support Assessment."
Hospital Leadership Team
A typical hospital includes these three leadership groups:
Top-level administration (e.g., chief executive officer,
chief financial officer, chief operating officer, chief medical officer,
chief nursing officer, chief quality officer, vice president of facilities
and other vice president-level staff).
- Board of trustees.
- Medical staff.
Hospitals vary with how they involve these groups in
decisionmaking. Depending on your goals for change, you should approach some
or all of these leadership groups to ensure buy-in.
influence of top management, board, and physician leadership on hospital
quality improvement efforts is detailed in: Weiner BJ, Shortell SM, Alexander
J. Promoting clinical involvement in hospital quality improvement efforts: the
effects of top management, board, and physician leadership. Health Serv Res
1997;32(4):491-510. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1070207/pdf/hsresearch00036-0116.pdf [Plugin Software Help].
||The tool for assessing leadership support be found in
Tools and Resources (Tool 1C, "Leadership
Assess the level of leadership support for this change effort. Look
carefully at the "yes" and "no" answers in the leadership support assessment.
If no senior managers have been designated to oversee patient safety, or no funds
are earmarked for patient safety, patient safety education, or champions for
fall prevention, launching a fall prevention program is likely to be
extremely difficult, if not impossible. Ideally, leaders will share the
urgency to improve and will help drive that urgency through the organization.
However, if their support is not adequate, take steps to inform leaders of
the importance and potential benefits associated with fall prevention.
Answer the following questions: Who are the key leaders? What
will get them on board, if they are not already on board? What will keep them
on board? Which senior leader can be the sponsor, link, or champion for this
Use what you learned about reasons for change identified by the
management and staff in your assessments.
for developing a business case for fall prevention can be found in Tools and
Resources (Tool 1D, "Business Case Form").
information on making the business case for fall prevention, see Forte J. How
to build a successful business case for a falls-reduction program. Best practices
for falls reduction: a practical guide. Am Nurse Today 2011;6(2). Special
Supplement. Available at: www.americannursetoday.com/article.aspx?id=7634&fid=7364.
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1.4. Who will take
ownership of this effort?
Beyond the support of organizational leaders, improvement
and change projects need strong advocates, members of the organization who are
committed to the project's goals and who can influence others to get involved.
Successful change projects must have broader support than just one or two
champions. Individuals who can take ownership of the effort can come from
various disciplines and may include physicians, nurse managers, physical or
occupational therapists, pharmacists, or staff members with a particular
interest and expertise in fall prevention. Some or all of these staff should
make up the interdisciplinary Implementation Team that will guide the
improvement effort, as described in section 2.
Assess your organization to identify who the potential
advocates of fall prevention are likely to be. Some may be obvious, but
others may not be immediately evident.
Who cares about this issue? Why might it be important to them?
Organizationally, what would be the logical home base for this
Would any individuals in that part of the organization be
willing to take ownership?
identifying potential owners or champions for the effort, consider visiting
the AHRQ TeamSTEPPS Web site, which offers tips and suggestions for enhancing
organizational readiness: http://teamstepps.ahrq.gov/abouttips.htm.
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1.5. What kinds
of resources are needed?
In addition to the Implementation Team, improvement projects
require resources of various kinds, depending on the size and scope of the
program. Launching an effort without first ensuring adequate resources can
derail your program at almost every step. Needed resources are likely to
include staff time for team meetings and initiatives, leadership time to
monitor and support team efforts, training and education time, and more
tangible resources such as new care products and communication materials.
Cultivating local expertise in fall prevention is particularly key in hospitals
that do not have a content expert readily available.
Consider creating a checklist to identify resource needs, such
as funds, staff education programs, and information technology support. At the
beginning of the program, the list of resources needed is likely to be broad
and will require refinement as the improvement efforts progress. In developing
the list, consider the resources already in place, such as a data system for
reporting fall rates and staff education programs. A detailed approach to
determining current prevention practices is described in section 2.2.2. At this early stage of determining
whether change is needed, the assessment of resources can be at a more general
||This tool can be found in the Tools and Resources section (Tool 1E, "Resource Needs Assessment").
Take the time to develop a list of resources that are likely to
be needed as part of a fall prevention program.
Ask for what you will need to accomplish some significant
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1.6. What if you are
not ready for full-scale change?
You should not move ahead with full-scale organizational
change until you are confident of organizational readiness. You can use the
checklist in section 1.7 to assess
each of the areas of organizational readiness for change that has been
discussed in this section. To the extent that readiness is not yet evident, or
is only partial, it is critical to address those areas. At a minimum, the
facility must have one senior leader who understands the importance of this effort
and is committed to supporting the effort both in terms of resources and
necessary changes to work processes. In addition, evidence of a broader
commitment to patient safety is an essential component. If any of these
elements are missing, you will need to first build support and readiness before
launching a full-scale change effort.
Some ways to build
support and readiness may include:
- Trying the changes in a single receptive unit to demonstrate success to the rest of the organization and build the case for change.
- Holding one-on-one meetings with key formal and informal leaders to present information about the need for change and persuade them that the improvement efforts will pay off.
- Collecting and sharing data on fall rates in your facility to establish program relevance.
- Identifying and recruiting program allies who can help spread the word.
- Conducting a general staff awareness campaign.
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Checklist for assessing readiness for change
The Organizational Readiness Checklist and other end-of-chapter
checklists are designed to provide toolkit users with ways to check their
progress through the assessment and implementation steps discussed in the
toolkit. They may be useful in ensuring that toolkit users have not skipped
essential steps (e.g., ensuring leadership support) in pursuing their fall
a Currie LM. Fall and injury
prevention. Patient safety and quality. an evidence-based handbook for nurses. Rockville,
MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No.
08-0043. Available at: www.ahrq.gov/qual/nurseshdbk/docs/CurrieL_FIP.pdf [Plugin Software Help].
b Oliver D, Healey F, Haines TP.
Preventing falls and fall-related injuries in hospitals. Clin Geriatr
c Wong CA, Recktenwald AJ, Jones
ML, et al. The cost of serious fall-related injuries at three Midwestern
hospitals. Jt Comm J Qual Patient Saf 2011;37(2):81-7.
d Go to www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/HACFactsheet.pdf [Plugin Software Help]
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