1. Are you ready for this change?

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

Drawing of jigsaw puzzle with the following pieces: Assess Readiness, Manage Change, Implement Practices, Best Practices, Measure, Sustain, Tools. Assess Readiness is highlighted.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?
Picture of binoculars, denoting practice insights.

Organizational Readiness for Change: Locally Relevant Considerations

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:

  • Some hospitals may experience significant turnover in senior leadership and nursing leadership.
  • Competing patient safety and quality priorities may affect resource availability.
This section of guide addresses these types of issues.

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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 rates?
  • Have there been any adverse events that were fall related?
  • Has your facility been the target of a legal action related to a fall?
  • 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 interdisciplinary responsibility.

Picture of a hammer, denoting a tool.
  • 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.
Picture of a checkmark, denoting an action step.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 your facility.
  • Determine your facility leadership's interests and needs in this area, and assess how much effort will be needed to obtain and sustain their support.
  • 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 justifying change.
  • 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 organizational members.
  • 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 think.

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1.2. Is there urgency to change?

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 2.2.

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 prevention.

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 ).

Picture of a checkmark, denoting an action step.
  • 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 with education.
  • Conduct a stakeholder analysis to identify key people and departments that may have a stake in the success of this program.
Picture of a hammer, denoting a tool.A template for stakeholder analysis can be found in Tools and Resources (Tool 1B, "Stakeholder Analysis").
Picture of 'at' symbol, denoting a linked tool or other resource.Consider using the introductory slide presentation developed by ECRI Institute. [PowerPoint® file, 240 KB; Plugin Software Help]
Note: ECRI Institute should be cited as the source.

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1.3. Does senior administrative leadership support this program?

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 section 2.1.1.

To assess leadership support and other questions raised here, consider using a facility-level assessment similar to Tool 1C, "Leadership Support Assessment."

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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.

The 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].

Picture of a hammer, denoting a tool.The tool for assessing leadership support be found in Tools and Resources (Tool 1C, "Leadership Support Assessment").
Picture of a checkmark, denoting an action step.
  • 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 effort?
  • Use what you learned about reasons for change identified by the management and staff in your assessments.
Picture of a hammer, denoting a tool.A template for developing a business case for fall prevention can be found in Tools and Resources (Tool 1D, "Business Case Form").
Picture of 'at' symbol, denoting a linked tool or other resource.For more 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.

Picture of a checkmark, denoting an action step.
  • 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 effort?
  • Would any individuals in that part of the organization be willing to take ownership?
Picture of 'at' symbol, denoting a linked tool or other resource.In 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 level.

Picture of a hammer, denoting a tool.This tool can be found in the Tools and Resources section (Tool 1E, "Resource Needs Assessment").
Picture of a checkmark, denoting an action step.
  • 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 changes.

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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:

  1. Trying the changes in a single receptive unit to demonstrate success to the rest of the organization and build the case for change.
  2. 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.
  3. Collecting and sharing data on fall rates in your facility to establish program relevance.
  4. Identifying and recruiting program allies who can help spread the word.
  5. Conducting a general staff awareness campaign.

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1.7. 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 prevention efforts.

Picture of a hammer, denoting a tool.The checklist for assessing readiness for change can be found in Tools and Resources (Tool 1F, "Organizational Readiness Checklist").

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/professionals/clinicians-providers/resources/nursing/nurseshdbk/docs/CurrieL_FIP.pdf.
b Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med 2010;26(4):645-92.
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 and www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/EducationalResources.html for details.

Current as of January 2013
Internet Citation: 1. Are you ready for this change?: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk1.html