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
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
Your hospital may find sustaining redesigned practices
challenging for reasons such as these:
section will provide suggestions to address these types of challenges.
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
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.
Return to Contents
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.
Return to Contents
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
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
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.
Return to Contents
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
Training for new employees and refresher training for current
Prompt filling of staff vacancies by human resources.
Prompt provision of needed supplies and equipment by facility
Help from information technology staff to assist with regularly
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
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
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
||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").
Return to Contents
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
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
||This article describes strategies to reinforce desired
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:
monthly fall meetings attended by the hospital fall committee cochairs,
managers, and clinical staff to address root causes of falls.
Importance of continued leadership support and staff dedication
at all levels.
Ongoing monitoring and measuring of fall rates.
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
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
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).
implementation team could use to reinforce the desired results of the
mobility program include:
efforts would highlight the priority of mobility at various levels of the
organization and would help create a culture throughout the institution of
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.
Return to Contents
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.
Return to Contents
Proceed to Next Section