2. How will you manage change?
Being ready for change is a necessary, but not sufficient,
prerequisite to changing your organization's approach to fall prevention. Even
when a health care organization is armed with the best evidence-based
information, willing staff members, and good intentions, the implementation of
new clinical and operational practices still requires additional careful
organizational planning. Once you have established organizational readiness,
the next practice change step is completing a thoughtful assessment of your
organization's current practices and knowledge about fall prevention.
Your timeline should balance the need to act systematically and
thoughtfully with the need to move quickly enough to maintain momentum by
demonstrating progress. This section is designed to help you manage change at
the organizational level. We will discuss managing change at the unit level in section 4 and sustaining change in section 6.
In section 1.4, you identified
members of the organization who would be willing to take ownership of the
improvement effort. As mentioned, we recommend that some or all of those
members serve on an Implementation Team to oversee the improvement effort and
manage the changes required. To maximize the possibility of successful
implementation of the fall prevention initiative, you need to consider the
How can you set up the Implementation Team for success?
should serve on the Implementation Team?
can you help the Implementation Team get started on its work?
How does the Implementation Team work with other teams involved in
What needs to change and how do you need to redesign it?
do you start the work of redesign?
is the current state of fall prevention practice?
What is the current state of staff knowledge about fall
How should goals and plans for change be developed?
goals should you set?
How do you develop your plan for change?
How do you bring staff into the process?
do you get staff engaged and excited about fall prevention?
How can you help staff learn new practices?
|| Managing Change: Locally Relevant Considerations
In trying to manage change at the organizational level, your
hospital may experience some of these challenges:
types of challenges are addressed in this section.
The need for an effective fall prevention program, an
interdisciplinary approach, and shared ownership and accountability not
penetrating through all levels of staff.
Issues with staffing and culture: high turnover rates, inertia,
and too many initiatives competing for staff attention.
Difficulty establishing interdisciplinary teams:
Many hospitals have nurse-driven fall prevention committees and
are transitioning to interdisciplinary teams.
Fall prevention roles need to be better defined across
disciplines, and some disciplines have not bought into the need to play a
proactive role in fall prevention.
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2.1. How can you set up the Implementation Team for
The center of successful improvement efforts in fall
prevention tends to be an interdisciplinary Implementation Team that has:
A strong link to hospital leadership.
Members with the necessary expertise.
A clearly defined aim (e.g., develop a program to reduce
fall incidence by 15% in our hospital in the next year).
Access to the resources needed to accomplish the aim.
If you already have a hospital fall prevention committee,
the committee can become your Implementation Team. This team should include
stakeholders who represent the broad range of organizational members with
potential roles in fall prevention.
Trying to find one person who can do all these things,
instead of a team, is both difficult and risky. Fall prevention is a process
that cuts across many different areas of hospital operations and thus requires
input from all those areas. In addition, forming a team ensures that efforts
will continue even if one or more members move to other activities.
The Implementation Team generally assumes overall
responsibility for the design and evaluation of a large-scale change in
clinical practices, working with and through other teams throughout the
facility. The relationships among these teams will be addressed in later
This interdisciplinary team will have responsibility for overseeing
the fall prevention program in your organization, making key design decisions,
working with unit-level teams to carry out improvement activities, and
monitoring progress. Thus, the implementation team will need some members with
clinical expertise and experience.
Successful teams have capable leaders who help define roles
and responsibilities and keep the team accountable for achieving its
objectives. You will face a number of decisions in setting up the team to lead
the fall prevention program. In section 1, we
discussed the process of choosing someone to spearhead your fall prevention
program, so that person should be identified and involved in the discussion of
these questions. Decisions that need to be made before convening the team
How do we determine members of the Implementation Team?
How can we help the Implementation Team get started on its work?
2.1.1. Who should serve on the
The most effective teams for overseeing a change project
such as this one have several characteristics:
An interdisciplinary team, including members from many areas
with the necessary expertise to address the problem. Senior leadership
support is a prerequisite for system change, but change itself comes most
effectively from the ground up. Change happens as teams that include frontline
health care workers actively engage in high-priority problem solving, such as
redesigning processes of care. Including bedside staff as members will be key
to tapping their practical knowledge and engaging them in the change process. Tool 2A ("Interdisciplinary Team")
provides a list of potential team members.
Strong link to leadership. While some organizations
have found that the only way to have adequate senior leadership support for an
initiative is to include a senior leader on the team, this may not be feasible
or appropriate in every case. As an alternative, consider asking senior
leadership to designate a member of the top management team as the champion for
the fall prevention program. The team's leader should stay in frequent contact
with the senior leader champion and can approach that person when the team
encounters obstacles or needs access to senior leadership.
Link to quality improvement expertise.The
Implementation Team will be strengthened by having a member with expertise in
systematic process improvement methods and in team facilitation from the quality
improvement or performance improvement department. If your organization does
not have a separate department with these functions, consider using informal
channels to identify a person with these skills to recruit to the team. In some
organizations, a member with improvement expertise successfully coleads the
Implementation Team with a clinical colleague.
Members who influence the areas that will need to be involved
in fall prevention. Sometimes it is not possible to anticipate every
area that needs to be involved. It is always possible to add team members later,
but new members will need to be oriented to the team's history and process.
You may find a checklist useful in considering potential
team membership. Your list can include the position/discipline, possible team
members, and area of expertise.
member checklist can be found in Tools and Resources (Tool 2A, "Interdisciplinary Team").
for Healthcare Improvement Web site ("Science of Improvement: Forming the
Team") provides both general principles for team composition and several
examples of different clinical improvement teams and their membership: www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx ).
Implementation Team Composition
Hospitals often find it very important that their team be
truly interdisciplinary. This composition ensures that as a group, they can
understand fall prevention from multiple perspectives and integrate hands-on
knowledge and expertise into their prevention efforts.
find the Interdisciplinary Team tool (Tool
2A) useful to identify additional Implementation Team members to invite
to team meetings. For example, hospitals use the tool to involve additional
individuals with such roles as risk manager, physical rehabilitation director,
and pharmacist. Hospitals report it is important to include senior leadership
to help secure resources and connect the team to other helpful staff and departments.
Because hospitals are organized differently, the exact titles and roles of
the people you invite to the team may be different from these examples.
2.1.2. How can you help the Implementation Team start its work?
Changing routine processes and procedures to alter the ways
people conduct their everyday work is a major challenge. Successful implementation
teams—teams that achieve their goals and sustain improved performance—pay
attention to the development of routines that make the new practices for fall
prevention better than existing practices. They identify and implement new
practices that are easier, more reproducible (not reliant on memory), and more
efficient than old practices.
The Implementation Team itself needs structure to achieve
its objectives. Items to settle on early include:
How often to meet (e.g., monthly).
Ground rules or guidelines for how to manage meeting time and for
how to communicate, both internally and externally.
Timeline for the team's work so that there is a shared
understanding of the level of urgency and priority this effort requires.
How will the team do its work? This question refers both
to the resources the team may need (information, material) and to its methods of
working. How will the team track issues raised, explored, and addressed? How
will the team assess current knowledge and practice? How will the team use that
information to redesign practice?
What is the team's agenda? This related question
emphasizes the importance of giving the team a clear charge and scope for its
work. Can leadership provide team members with a clear understanding of the
short- and long-term goals and timeframes for the implementation of improved
fall prevention practices? For example, leadership may provide the team with a
written charge that specifies target dates and improvement goals.
Establish the scope of the Implementation Team's charge.
Develop a clear statement of the team's charge.
Ensure that senior leadership agrees with this charge.
Make sure that the team has access to the necessary tools and
structures to allow it to succeed.
Make sure that team members understand why they have been
selected, and find ways to recognize their efforts.
Ask the member from the quality improvement or performance
improvement department to orient the team to key principles and approaches
used in process redesign work.
Ensure that the team has the information it needs about the
scope of the problem of falls in your facility (e.g., fall rates,
repeat fall rates, severity of injury), the reasons for the team's work, and
the expected outcomes.
Make sure the team meets regularly at the most convenient time
and place and that it meets often enough to make progress.
Develop a timetable for specific team tasks and assign members
to be responsible for completing those tasks.
for Healthcare Improvement Web site ("Science of Improvement: Setting Aims") has
guidance on setting team goals and other aspects of team startup: www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementSettingAims.aspx .
2.1.3. How does the Implementation Team work with other teams involved in
The remainder of this section discusses activities that the
Implementation Team will typically be charged with, but the Implementation Team
cannot carry out the entire program alone. The Implementation Team will need to
collaborate with at least the staff who provide routine patient care in any
unit where changes are to be implemented. These staff may be physically based
on the unit (e.g., nurses or nursing assistants) or may be assigned to work
with specific units (e.g., rehabilitation therapists, pharmacists, or
physicians). We call these staff the Unit Team. Both teams have unique
responsibilities but communicate and work together to make the program a
The Implementation Team will look at the big picture,
including strengths and opportunities in current practices and the current
status of prevention and fall incident reporting. This team will then identify
needed changes and the specific practices, tools, and resources needed to
implement these changes. Unit Teams, with members also represented on the
Implementation Team, will actually implement the changes, integrating them into
existing workflows and providing feedback about how the changes work. The Unit
Team should include staff from all shifts and will have ongoing responsibility
for maintaining effective fall prevention practices.
No single team can make the program a success by itself. To
help develop the Unit Team, the Implementation Team should:
Outline roles for the Unit Team members that are clear and
Consider each Unit Team member's existing responsibilities on the
unit and how the unit team member's new role interacts with those
Define what ongoing communication and reporting are needed and
what the best linking methods across the Unit Team and the Implementation Team
might be. For instance, in some organizations, Unit Champions provide
this coordination function. Unit Champions belong to both the Implementation
Team and their own work units and thus serve as critical communication links.
Keep in mind that there is more than one way to organize. A
useful guide is to consider how Implementation Teams for other clinical change
efforts have operated successfully within your organization. Your organization's
quality improvement or performance improvement experts are likely to have
expertise in how to best organize and coordinate such teams. In many hospitals,
the training and development area may also be a resource for team organization
Clarify the Unit Team's roles in the change process.
Define the communication that is needed and the methods for
linkages across teams.
Return to Contents
2.2. What needs
to change and how do you need to redesign it?
In this section, we identify the steps the Implementation
Team needs to take to assess the current state of policy, procedures, and
practice, and we indicate tools that may be useful in this process. These steps
are based on the principles of quality improvement, defined broadly to include
system redesign and process improvement. These methods are appropriate for an
effort that seeks to prevent falls by improving quality of care.
2.2.1. How do you start the work of redesign?
For the Implementation Team, the work of redesign has
already begun through gathering the information about organizational readiness
(go to section 1) and defining the team's members
and structure. This quality improvement process may already be familiar to your
organization. If you are not sure about the strength of your organization's quality
improvement infrastructure, you may want to complete Tool 2B, "Quality Improvement Process."
Committees that oversee quality improvement for the hospital
may go by different names, such as Quality Council or Patient Safety Committee.
If some of the quality improvement processes listed in this inventory are not
fully operational or present in your organization, you may need to build your
team's improvement capability. In addition to identifying team members with
improvement expertise, the Implementation Team can develop basic improvement
skills through an education process.
Improvement efforts tend to be most successful when teams
follow a systematic approach to analysis and implementation, and there are
multiple approaches to consider. Team leaders and members may want to consult
more general resources for approaches to quality improvement projects, such as
information on the Plan, Do, Study, Act (PDSA) approach (described below in
If your organization already has well-established quality
improvement processes and structures, it will be beneficial to connect the fall
prevention program with those processes. For example, if you have an
established reporting structure to leadership, including this program will help
keep it on the leadership agenda. If managers are already evaluated based on
their quality improvement efforts and results, making this program a part of
the large quality improvement enterprise in your organization will help ensure
||Assess your organization's current resources for quality improvement
by completing the "quality improvement process inventory" found in the Tools
and Resources section (Tool 2B, "Quality
for Healthcare Improvement Web site ("Science of Improvement: Testing
Changes") includes a brief summary of the PDSA cycle and a clinical example of
it in use: www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx .
Examples of Improvement Processes
(Plan, Do, Study, Act)
PDSA is an iterative process based on the scientific
method in which it is assumed that not all information or factors are known
at the outset; thus, repeated cycles of change and evaluation will be needed
to achieve the goal, each cycle closer than the previous one. With the
improved knowledge, you may choose to refine or alter specific goals.
For more information, refer to Chapter 5 in the RAND
report Putting Practice Guidelines to Work in the Department of Defense
Medical System. A Guide for Action, available at www.rand.org/pubs/monograph_reports/2007/MR1267.pdf [Plugin Software Help] .
Hopkins Translating Research Into Practice (TRIP) Model
This model elaborates a specific strategy for researchers,
clinicians, and managers to collaborate in quality improvement. The model
uses 4 "E's" (Engage, Educate, Execute, and Evaluate) and has been
successfully applied in both large-scale quality improvement (QI)
collaboratives and small-scale, clinically focused QI projects at the
individual unit or hospital level. For more information, refer to: Pronovost
PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model
for large scale knowledge translation. BMJ 2008;337:a1714.
A practical case study applying this model at an
individual unit level is described in: Needham DM, Korupolu R.
Rehabilitation quality improvement in an intensive care unit setting:
implementation of a quality improvement model. Top Stroke Rehabil
Developed at Motorola, Six Sigma methodology is based on
the careful analysis of data on process deviations from prespecified levels
of quality and use of redesign to bring about measurable changes in those
rates. Six Sigma incorporates a specific infrastructure of personnel with
different levels of training in the method (e.g., "Champions," "Black Belts")
to take different roles in the process. For more information, read "What Is
Six Sigma?" at: www.motorola.com/web/Business/_Moto_University/_Documents/_Static_Files/What_is_SixSigma.pdf.
Production System (TPS)
TPS is an integrated set of practices designed to systematically and
continuously identify problems at the point of production and empower workers
to identify and fix problems when they are identified. For more information,
refer to"Reducing Waste and Inefficiency in Health Care Through Lean Process
Redesign: Literature Review" at www.ahrq.gov/qual/leanprocess.htm.
|| Further reading relevant to quality improvement:
Rogers EM. Diffusion of innovations. New York: Free Press;
Langley GJ, Nolan TW, Provost LP, et al. The improvement guide:
a practical approach to enhancing organizational performance. 2d ed. San
Francisco: Jossey-Bass; 2009.
2.2.2. What is the current state of your fall prevention practice?
The work of redesign requires an assessment of your
organization's current practices. In addition to the tools suggested below, you
may want to look ahead to section 5 for additional
tools for assessing current fall rates and care processes to prevent falls. We
suggest looking carefully at the gap between current practice and the recommended
practices discussed in section 3. For example:
Do any care processes already follow best practices?
Do others diverge in small ways or in major ways?
Which gaps are organizationwide, and which are specific to one or
If your hospital is large and complex enough that you
suspect variation in current practice across units, the Implementation Team may
want to start by focusing on one or two units.
Understanding the Organizational Context of Fall Prevention Practice
As a preliminary step in documenting prevention practices on
the units, the team will need to review the organizational context for the
practices. Among the questions to consider:
Have there been prior efforts to improve fall prevention? If yes,
are there lessons on which you can build? For example, what supported those
efforts? What barriers were encountered and how can you avoid the same
Are staff who prescribe and review medications (e.g., physicians
and pharmacists) involved in fall prevention practices? In what ways? What are
How are rehabilitation staff involved in fall prevention? In what
ways do rehabilitation staff and nurses coordinate their efforts to prevent
How is information about patient fall risk factors documented and
shared? What metrics, if any, are currently used to assess organizational
performance with respect to managing these risk factors?
Understanding Current Processes on the Units
To change practice, it is critical to understand what the
current practices are. The fact that fall prevention has taken on new urgency
reflects one or more perceived performance problems in this area. Thus, it is
important to identify any gaps between current best practices and actual work
practices. For example, staff may report a policy of accompanying all patients
with abnormal gait to the bathroom but may not always do this. The extent of
these gaps is usually not known until current practice is systematically
examined. Understanding where any unit that is targeted for change is starting
from will help you identify gaps in knowledge and resources and will allow you
to see how much progress is made.
Process Mapping To Document Current Practices
One useful approach to understanding current practices is to
use process mapping to examine key processes where fall prevention
activities could or should be happening. (Detailed instructions on process
mapping may be found in Tool 2C, "Current
Mapping can specify which organizational unit or person
carried out each step in the process, with particular attention to both the
movement of the patient and the movement of information about the patient. The
goal of process mapping is to come to a common understanding of how a
particular care process is being carried out, which then leads to further
discussion about how the process should be carried out.
There are different approaches to process mapping, but each
approach provides a systematic way to examine each step in the delivery of a
specific procedure or service. Experimentation with different approaches
can be helpful during the redesign planning phase because each approach can
provide different insights and answer different questions.
Integrating Change Into Current Work Routines
Beyond gap analysis and mapping of current practices, the
team should consider how the recommended practices for fall reduction can be
integrated into current workflow and processes, rather than layered on top of
them. One way to approach this task is to systematically assess the barriers to
using evidence-based practices. For example, if eligible patients are not being
mobilized out of bed within a specific period of time from admission, what are
the reasons? Is it due to a lack of staff awareness that this should happen? Is
it because nobody has specific responsibility for this task? Is it because
staff lack training in how to mobilize patients or document that they did so?
Assess current practice on a sample of representative units to
determine which, if any, fall prevention practices are already in place (see
sections 3 and 5). For example, is an initial risk factor assessment completed
within a certain timeframe of admission? Are the results used to determine
risk factors that can be intervened upon?
Use process mapping to describe current prevention practices
and to identify problem points. Process mapping will enhance understanding of
how and when fall prevention fits into existing processes such as surgical or
medical admissions, or admissions through the emergency department.
Compare assessment results across units to determine which
prevention challenges are organizationwide and which may be unit specific.
Determine which practices need changing and consider how the
new practices can be built into ongoing routines (discussed in section 4.1).
||This worksheet in Tools and Resources has a possible
approach to process mapping (Tool 2C, "Current
Use these worksheets to assess existing fall prevention
practices in your facility (Tool 2D, "Assessing
Current Fall Prevention Policies and Practices").
would like to learn more about process mapping, the AHRQ publication Toolkit
for Redesign in Healthcare provides a detailed example and data
collection tools, starting on page 14: www.ahrq.gov/qual/toolkit/toolkit.pdf [Plugin Software Help].
2.2.3. What is the current state of staff knowledge about fall prevention?
Due to turnover, differences in training, and other factors,
staff members will likely vary in their knowledge of recommended fall
prevention and treatment practices. To address these gaps through education,
you need to know what the gaps are. Thus, assessing the current state of staff
knowledge is critical.
One assessment tool is the Fall
Knowledge Test (Tool 2E), which was developed through a consensus process
and used in a randomized controlled trial to measure nurses' knowledge about
falls and their prevention (see box below for details).
By themselves, assessment of knowledge and training focused
on increasing knowledge are not enough. Training needs to be integrated with
current work routines (go to section 4.3.4). Based
on analysis of the knowledge test results, the team can assess barriers to
change among the staff that most likely will need to be addressed, a process
that began with assessing their attitudes, as suggested in section 1. These barriers can be discerned through
the assessment of staff knowledge and assessment of current practice. For
instance, do staff believe that risk factor assessment is unnecessary because
preventive procedures are applied to "everyone"? Keep in mind that not all
barriers may be evident at the outset, so it is important to be attentive to
potential barriers as the first wave of changes are implemented.
Administer an inventory of fall prevention knowledge to staff
members. See the tool listed below for this task.
Consider collecting information on unit and occupation of
respondents so that you can use this information to analyze results and
better target training. Since this is an educational needs assessment, we do
not recommend asking staff to include their names, unless they want direct
feedback on their score. Using names may decrease participation.
Develop methods to correct knowledge gaps and misunderstandings.
||The following tool can be used to assess staff knowledge:
||A 14 multiple-choice question knowledge test was
administered before and after staff education following implementation of the
Singapore Ministry of Health Fall Prevention Clinical Practice Guideline.
details, refer to: Koh SLS, Hafizah N, Lee JY, et al. Impact of a fall
prevention programme in acute hospital settings in Singapore. Singapore Med J
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2.3. How should goals and plans for change be
2.3.1. What goals should you set?
Once the Implementation Team completes its analysis of the
gaps in fall prevention, the team will need to review the evidence on various
best practices (discussed in section 3) that
may help address those gaps. However, before turning to those steps, the
Implementation Team will need to set goals for improvement. These goals should be
related both to outcomes (e.g., a reduction in falls per 1,000 bed days) and to
processes (e.g., adherence to hourly rounds).
Goals should be related to data the hospital already collects
or can collect (e.g., through incident reports or a chart audit). External
benchmarks should be used with caution, since fall rates vary substantially by
hospital unit (go to section 5). Goal-setting will help
determine the team's next steps to redesign fall prevention activities within
Once goals are chosen, your gap analysis may reveal problems
in performance related to care processes such as these:
Staff are not conducting the initial fall risk factor assessment
within 24 hours of admission.
Patients' medications are rarely reviewed for fall risk.
Patients who are at risk for prolonged weakness from their
hospital stay are not mobilized within 48 hours of admission.
Patients with frequent toileting needs are not assisted in a
In this case, you may want to set goals related to the
improvement of these measures to certain levels within a certain timeframe,
such as improving the number of at-risk patients who are mobilized within 48
hours from 50 percent to 75 percent over the next 3 months. Alternatively, you
may find that after you examine staff knowledge, certain gaps should be
addressed. Other reasons for poor performance could be confusion in roles or a
lack of staff communication. In these cases, goals could be set for addressing
and improving these issues within a certain timeframe.
Set goals for improvement based on outcomes and processes.
Identify benchmarks against which to judge goals and progress.
Use goals to guide next steps in redesigning fall prevention.
2.3.2. How do you develop the plan for change?
Once goals have been set, the next step is to begin
developing a more specific plan for implementing new practices and for
assessing that plan through the consistent collection and analysis of data.
This plan will be extended and refined by work to be completed in response to
additional questions (described in section 4).
While this plan will need to be flexible to meet the needs
of specific units, a comprehensive plan is still necessary. The best practices
that will be discussed in section 3 are
critical to the implementation plan but are not enough, as they must be
implemented within the context of many other factors. Also, it is important to
begin thinking early about sustaining the improvements you put into place (as
discussed in section 6). Thus, the implementation
plan should address:
Membership and operation of the interdisciplinary Implementation
Standards of care and practice to be met.
Ways gaps in staff education and competency will be addressed.
Plans for rolling out new standards and practices, where needed.
Staff accountable for monitoring the implementation.
Ways changes in performance will be assessed.
Ways this effort will be sustained.
||The "plan of action" found in
Tools and Resources can be a useful template for developing your implementation
plan (Tool 2F, "Action Plan").
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2.4. Checklist for managing change
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