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Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

2F: Action Plan

Background: The purpose of this tool is to provide a framework for outlining steps that will be needed to design and implement the fall prevention initiative.

Reference: Adapted from material produced by MassPro, a participant in the Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

How to use this tool:

  1. This tool should be filled out by the Implementation Team leader in consultation with the quality improvement manager.
  2. Note the date and the objective. A sample objective is provided.
  3. The form lists six key tasks. For each, list in the second column the steps that will be taken to address the task, including tools to be used.
  4. In developing the plan, it is not expected that you will provide results, only that you will lay out what needs to be done.
  5. In the last two columns, determine who will have lead responsibility for completing each task, and estimate an appropriate timeframe for completing the activities.
  6. Use the plan as a working document that can be revised. As you begin to carry out the plan, you may need to make adjustments and add details to the later tasks.

Use the completed sheet to plan, manage, and carry out the identified tasks. The plan should guide the implementation process and can be continually amended and updated.

A sample completed form is shown below, followed by a blank form.

 

Fall Prevention Action Plan
Date: November 16, 2011

Improvement Objective: Implement standard fall prevention practices within 6 months.

Key Interventions/Tasks Steps To Complete Task and Tools To Use Team Members Responsible for Task Completion Target Date for Task Completion
  Examples Examples Examples
1. Analyze current state of fall prevention practices in this organization. Identify strengths and weaknesses using process mapping and gap analysis. Tool 2C and Tool 2D. Team leader, RNs Within 6 weeks from initiative start
Assess the current state of staff knowledge about fall prevention. Tool 2E. Education department Within 6 weeks from initiative start
Set target goals for improvement. QI department Within 8 weeks from initiative start
2. Identify the set of prevention practices to be used in redesigned system. Determine how comprehensive universal fall precautions should be performed. Implementation Team Within 12 weeks from initiative start
Decide which scale or questions will be used for performing fall risk factor assessment. Implementation Team Within 12 weeks from initiative start
Decide which fall prevention activities should be in your program. Clinical staff members Within 12 weeks from initiative start
3. Assign roles and responsibilities for implementing the redesigned fall prevention practices. Determine who will complete the fall risk factor assessment on admission. Tool 4A. Implementation Team Within 16 weeks from initiative start
Identify unit champions. Team leader Within 16 weeks from initiative start
Determine how prevention work will be organized at the unit level, such as paths of communication and lines of oversight. QI team Within 16 weeks from initiative start
4. Put the redesigned set into practice. Engage staff and get them excited about the changes needed. Team leader, unit staff Within 12 weeks from initiative start
Pilot test the new practices. QI department Within 20 weeks from initiative start
5. Monitor fall rates and practices. Determine how incidence data on fall rates and fall prevention care processes will be collected. Tools 5A and 5B. QI department Within 6 weeks from initiative start
Organize quarterly reviews of data. QI department Within 6 weeks from initiative start, ongoing
6. Sustain the redesigned prevention practices. Ensure continued leadership support. Team leader Within 4 weeks from initiative start, ongoing
Ensure ongoing support from other units such as facilities management and IT. IT, facilities management, PT, dietitians Within 40 weeks from initiative start
Designate responsibility and accountability for fall prevention oversight and continuous quality improvement. Team leader and Implementation Team Within 40 weeks from initiative start

Fall Prevention Action Plan
Date:           

Improvement Objective:

Key Interventions/Tasks Steps To Complete Task and Tools To Use Team Members Responsible for Task Completion Target Date for Task Completion
1. Analyze current state of fall prevention practices in this organization.      
     
     
2. Identify the set of prevention practices to be used in redesigned system.      
     
     
3. Assign roles and responsibilities for implementing the redesigned fall prevention practices.      
     
     
     
4. Put the redesigned care processes into practice.      
     
     
5. Monitor fall rates and practices.      
     
     
6. Sustain the redesigned prevention practices.      
     
     

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