6. How do you sustain an effective fall prevention program?

The only step more difficult than implementing practice change is ensuring that those changes become woven into the day-to-day fabric of operations so that they are sustained beyond the initial formal improvement effort or special campaign. It is sometimes easy to adopt new practices in response to an immediate need, such as an impending Joint Commission visit, and considerably more difficult to maintain those practices over time. To sustain improvement, changes need to become so integrated into existing organizational structures and routines that they are no longer noticed as separate from business as usual.

While sustaining changes logically follows initial improvements, it is important to begin thinking early in the improvement process about what will be needed to make lasting change. Throughout the implementation process, you should consider questions such as:

• Who will be responsible for sustaining fall prevention efforts on an ongoing basis?
• How will you continue to monitor fall rates and fall prevention care processes?
• What types of organizational support do you need to keep the new practices in place?
• How can you reinforce the desired results?

Sustaining Redesigned Prevention Practices: Locally Relevant Considerations Your hospital may find sustaining redesigned practices challenging for reasons such as these: Fall prevention may be viewed as a time-limited initiative rather than an ongoing program. Change specific to fall prevention has not been incorporated into routine behavior. More unit-based champions are needed. Staff need to take ownership of fall prevention. Mechanisms are needed to provide feedback to staff on the effectiveness of fall prevention strategies and to celebrate success. This section will provide suggestions to address these types of challenges.

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6.1. Who will be responsible for sustaining active fall prevention efforts on an ongoing basis?

Sustaining efforts at fall prevention within your hospital requires responsibility for the hospital's fall prevention program to be clearly assigned (go to section 2). A key decision for your organization will be in what form to keep the Implementation Team going. If you have a standing fall prevention committee and it functioned as the Implementation Team, the fall prevention committee can continue to oversee the program. If the Implementation Team was chartered on a time-limited basis and there is no fall prevention committee to hand off to, a subset of Implementation Team members could form the core of a new standing fall prevention committee. The key message is that a successful fall prevention program needs to be an ongoing effort, and oversight cannot end after initial implementation is complete.

For ease of presentation in the rest of this section, we will refer to the group responsible for fall prevention going forward as the Sustainability Team, whether it is the original Implementation Team or a different group. The Sustainability Team will serve as a key dissemination point for new information (e.g., team education sessions with invited speakers) and will take up new challenges (e.g., revise online documentation forms).

The Sustainability Team will ensure that data collection and regular reporting of fall rates occur and are fully integrated into routine work processes. Regular meetings will be important in discussing outcomes and updating materials and policies on an ongoing basis.

An important element for keeping the Sustainability Team going is to allow a variety of levels of participation in team activities. There may be a core group of individuals who meet on a monthly basis to review fall data and others who need only attend meetings on an "as needed" basis. This approach allows people to participate in a way that is respectful of their time and helps to maintain a positive dynamic at team meetings.

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6.2. How will you continue to monitor fall rates and fall prevention care processes?

Continuing to monitor fall rates and fall prevention care processes is critical for the sustainability of a fall prevention program. (Details on how to measure fall rates and fall prevention care processes are provided in section 5. Information on the Plan, Do, Study, Act approach to continuous improvement is provided in section 2.2.1.) Measurement is necessary for improvement, particularly as a check to ensure the program is not veering off track. Measurement is also needed to show ongoing success of the program to leadership. Leaders will be more willing to invest in a program that has credible evidence of success.

To regularly measure fall rates requires setting up a routine workflow (a scheduled set of activities and tasks performed by designated people) for data collection. You will need to decide who will calculate fall rates from incident reports and who will audit fall-related care processes to ensure these occur as they should. You also will need to decide to whom these data will be reported and what will be done with the data. For example, how soon prior to each meeting of the Sustainability Team will the data need to be sent for review?

In addition, the Sustainability Team will need to discuss what change in fall rates represents a real success (or concern) for the hospital, versus fluctuations in the data that can be explained by other changes, to avoid inappropriately reacting to noise in the data. For example, more patients with fall risk factors might be admitted during the flu season, so the fall rate might go up during that time. Or the hospital may have migrated to a new incident reporting system, which improved staff adherence to reporting falls, thereby making the fall rate higher.

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6.3. What types of ongoing organizational support do you need to keep the new practices in place?

While the frontline work to prevent falls depends on unit staff, the Sustainability Team will need support from other parts of the organization to be successful. Support for the Sustainability Team can include activities such as:

• Training for new employees and refresher training for current employees.
• Prompt filling of staff vacancies by human resources.
• Prompt provision of needed supplies and equipment by facility management.
• Help from information technology staff to assist with regularly reporting data.

If your organization is using Unit Champions, the Sustainability Team will need to consider strategies to keep them engaged and a method to replace Unit Champions when the original champions change responsibilities or positions. Similarly, if you do not have Unit Champions but multiple staff who serve as fall prevention resource staff on the units, you will need processes for keeping them engaged and replacing them when needed.

Communication is essential to keep staff involved and up to date. The Sustainability Team therefore will need to consider how to engage and communicate with the staff at large as new practices become integrated into ongoing operations. Consider ongoing information briefs in your staff bulletin. Posters can also be used; rotating them every few weeks may be important in keeping staff engaged. Make fall prevention a standard part of yearly staff education fairs or other similar events.

Integrating the Sustainability Team into the existing hospital organization will help ensure it can continue its mission. To further solidify ongoing support, you should determine to which oversight committee the Sustainability Team will report in the larger organizational structure. The most appropriate committee will depend on the structure of your organization. In some places it may be the Patient Safety Committee, in others the Quality Council.

Communication with the oversight committee should include not only updates on patient outcomes (e.g., fall rates), but also the financial implications of maintaining the fall prevention program (e.g., in terms of hospitalwide cost savings due to fewer falls, after program costs are accounted for). Reviewing the business case (go to Tool 1D) for fall prevention with leadership may be helpful, especially in cases of leadership turnover.

In addition to assessing changes in processes and outcomes of care, the Sustainability Team will need to examine the extent to which organizational structures and routines have changed in response to the fall prevention program. Without such change, it is possible that only short-term gains will be accomplished. Examples of items that might be assessed are described below.

Examples of assessment items for structures and routines that support fall prevention: Are unit staff very familiar with their role in preventing falls and how their role relates to other staff members? Are there unit experts who can be given extra training and work within units to maintain fall prevention awareness and knowledge? Are there systems and prompts in place to ensure that care is carried out appropriately? For example, does the electronic health record have a section on assessment and management of fall risk factors? Have barriers to obtaining needed supplies and equipment, such as assistive devices, been addressed? Is performance routinely tracked? Are performance data regularly reported to staff? Is there a committee that monitors fall rates and care processes and ensures that needed resources are available to prevent falls? Is hospital leadership engaged in the process of sustaining the fall prevention program (e.g., by being invited to visit units to view ongoing fall prevention activities or by meeting with the committee that oversees fall prevention)?

Key elements for a thriving Sustainability Team are summarized in Tools and Resources (Tool 6A, "Sustainability Tool").

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6.4. How can you reinforce the desired results?

Generating and maintaining excitement about change is critical to success. Given the obstacles to implementation, improvements in performance measures may not initially be evident. Even with good implementation, fall rates may appear to trend upward initially due to better reporting. It is thus important to find small successes early on that can be rewarded.

Another barrier to sustainability is staff turnover. To address this barrier, ensure that orientation for new clinical staff is modified to include a focus on fall prevention and that new staff are appropriately integrated into their unit's fall prevention program. This will help to maintain a unit culture that is positively oriented toward fall prevention.

This article describes strategies to reinforce desired outcomes: Weinberg J, Proske D, Szerszen A. An inpatient fall prevention initiative in a tertiary care hospital. Jt Comm J Qual Pat Saf 2011;37(7):317-25. Key points from this article include: Importance of continued leadership support and staff dedication at all levels. Ongoing monitoring and measuring of fall rates. Ongoing monthly fall meetings attended by the hospital fall committee cochairs, managers, and clinical staff to address root causes of falls.

 

To reinforce desired results, you also need to be aware of obstacles to sustaining your fall prevention program. For example:

• Old habits have a way of resurfacing. People may slowly go back to old approaches. This tendency supports the need for ongoing refresher training in the context of each unit's needs.
• Practices that had become accepted may suddenly be more difficult to perform or the availability of needed resources may change. Such unintended consequences of quality improvement are well recognized. For example, budget cuts may limit the number of sitters/safety attendants available to monitor very high risk patients for falls.

One Hospital's Mobility Program: An Application of Toolkit Concepts To show how this toolkit can apply in real life, we have provided a real example of one hospital's attempt to improve its care. We chose an example of a mobility program, because mobility programs have been shown to decrease hospital length of stay and costs and to increase the likelihood that a patient is discharged home rather than to a nursing home or rehabilitation facility. The hospital (an academic medical center) was concerned about patients' decline in mobility during inpatient stays, a factor that puts patients at risk for falls, but did not have enough physical therapy staff to provide sufficient mobility training. We outline the hospital's change process below. Readiness for change: Although senior leadership and medical staff had several discussions about the importance of maintaining patient mobility, the hospital lacked a strong promobility culture. One particular clinical event helped create urgency for implementing a mobility program. A transporter had difficulty transferring one patient into his car and the patient was concerned about how he would get out of the car when he got home. This was a wake-up call to staff because they realized the patient had not been out of bed since admission but needed to be able to get out of his car and into his home on his own after discharge. However, the mobility program did not begin until a newly hired individual within the Nursing Department was tasked with implementing the change. This new individual was committed to the program's goals and was able to pull together the right team to initiate the mobility program. Best practices and planned implementation: The mobility program was based on the principle that bed rest should not be the default for patients and uses a nurse-driven plan of care. As long as a physician has not set the patient to restricted mobility, the nurse follows the default electronic order set and progressively moves the patient through a mobility scale from 1 (turn patient) to 6 (ambulation with assist as needed). Nurses and patient care technicians take primary responsibility for patient mobility, with physical therapy or medical staff directing the mobility plan if there is a skilled need and/or weight-bearing limitations. Implementation: The implementation efforts were led by an interdisciplinary team that included physical therapy, nursing, and medical staff. The team implemented the program in two pilot units (medical intensive care and trauma/orthopedics), followed by a hospitalwide launch. Initial education included general computer training on the order set and a 2-hour nurse training on how to achieve each level of the mobility scale. Super-users on the pilot units helped train the other units. The units use a status board to present key patient information, including the mobility score, and physicians can quickly see and check where patients are on the scale. Physicians also use interactions with patients as a training opportunity. When at the bedside with residents and nurses, one physician often talks to patients about their mobility score and encourages them to progress. The implementation of the mobility program had positive benefits in creating more opportunities for discussion about patient mobility between physicians, nurses, and patients. The team experienced some barriers to implementation. It was difficult for some staff to change from assuming patients should be on bed rest to encouraging progressive increases in mobility. Nursing staff remembered previous experiences with patients falling and worried that fall rates would increase with increased ambulation. To reduce this fear, the team connected staff with nurses on successful units to share strategies for successful implementation. Monitoring change: Measuring processes and outcomes is one of the implementation team's next steps. Although objective data have not been collected yet, the team reports that many units have successfully adopted a promobility culture and more patients are standing or sitting in a chair than before. Sustaining the program: The implementation team recently faced some challenges in sustaining the program after moving to a new facility. The new facility has patient handling equipment to help staff move patients, which has introduced new questions about the mobility scale. The team has had to retrain staff to emphasize that moving a patient into a chair using a lift does not mean that the patient has progressed from "reclining in bed" (mobility 2) to "getting to chair on own" (mobility 5). Strategies the implementation team could use to reinforce the desired results of the mobility program include: Demonstrating reductions in the risk of falls and improved independence at discharge. Having unit champions reinforce discussions about mobility as part of the care plan on each patient, at interdisciplinary rounds and case conferences. Providing continuing education sessions that emphasize mobility. Hosting an annual "mobility day" at the hospital. These efforts would highlight the priority of mobility at various levels of the organization and would help create a culture throughout the institution of maintaining mobility.

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6.5. Summary

Significant time and effort have gone into getting your hospital to this point. By now, you have been successful at changing how things get done and in implementing best practices for fall prevention. You have systems in place to ensure that these best practices become the standard way care is now provided. Because of these changes, you can now demonstrate how your patients have better outcomes with fewer falls. These are major achievements for the Implementation Team and the hospital, and everyone should be congratulated for this collective effort.

Finally, always remember that no matter how well you are doing, sustained attention is still needed to keep improvements on track. Perfection in fall prevention is never achieved. There are always additional steps to get closer to the ideal of a fall-free hospital.

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