Now you are ready to begin implementing the fall prevention practices you have identified. No matter how good your fall prevention program is in concept, if it is not used by the staff it will not be successful. To this point, you have looked at your organization's readiness to improve fall prevention (section 1); assessed needs, set goals, and begun preparing for change (section 2); and examined best practices (section 3). In this section, the Implementation Team will work with the Unit Teams to implement the new prevention practices at the frontline care level.
Your organization may already be using some of the best practices that you have identified for implementation, but other practices will involve changes in the way you complete tasks. For the new set of practices to be fully implemented and sustained, it will need to be customized to your organization and integrated into ongoing work processes.
The questions in this section will guide you in multiple aspects of implementation. To successfully implement your change program, you should answer three sets of questions:
- What roles and responsibilities will staff have in preventing falls?
- How do you assign roles and responsibilities?
- What role will the Unit Team play?
- What role will the Unit Champions play?
- How should the prevention work be organized at the unit level?
- What fall prevention practices go beyond the unit?
- How do you put the new practices into operation?
- How do you manage the change process at the front line?
- How do you pilot test the new practices?
- How do you get staff engaged and excited about fall prevention?
- How can you help staff learn new practices?
|Implementing Best Practices: Locally Relevant Considerations
Implementing best practices requires attention to detail. Some issues that may need to be sorted out at your hospital include:
In section 2 you examined current practices and identified aspects needing improvement; in section 3 you reviewed best practices. Now you need to define specifically what needs to change to implement the best practices you have chosen and to decide who is going to do what. Specific areas of responsibility and paths of communication and accountability will be needed.
Hospitals and units within them vary in their staffing patterns and usual ways of doing business. You will need to consider staff roles based on the features of your organization overall and the individual units involved in fall prevention. The Implementation Team will need to involve members of the Unit Team, especially the unit managers, in these decisions.
Staff roles should be clearly defined so that Unit Team members will understand if and how their roles will change. If you, as the Implementation Team leader, will implement the fall prevention program with current staff, you will need to take their skills and strengths into account in allocating responsibilities. You will need to consider not only what individual responsibilities are, but also how the roles interact and what ongoing communication and reporting are needed.
The questions below will guide you through the process of considering and specifying the roles and responsibilities of the unit staff and Unit Champion. The questions also will guide you in deciding how best to organize work at the unit level and how to customize the set of practices for specific work units in your organization.
4.1.1. How do you assign roles and responsibilities?
Think about who will perform each specific task identified for your chosen set of best practices. Responsibilities should be assigned based on the relevant formal training and informal work experience of each profession or individual. In some cases, a group will perform a task based on their specific role or title, such as certified nursing assistants (CNAs). Other tasks may be assigned to a specific individual. In that case, always make sure you have a backup; it is important that everyone knows who the backup is when the assigned individual is unavailable.
As you work through this section, you should consider taking each task required to implement your chosen fall prevention practices and entering it into the summary page of the worksheet provided as Tool 4A, "Assigning Responsibilities for Using Best Practices, in Tools and Resources. Then assign specific individuals or groups to each task. Sections 4.1.2 through 4.1.4 include examples of responsibilities different staff might take on; those examples are summarized in Tool 4B, "Staff Roles." In making these assignments, make sure you work with the unit manager or Unit Champions from the units in which you are implementing change.
|In Tools and Resources, you can find a worksheet to use in deciding how responsibilities will be assigned in your organization (Tool 4A, "Assigning Responsibilities for Using Best Practices") together with a summary page illustrating how responsibilities might be organized (Tool 4B, "Staff Roles").|
4.1.2. What role will members of the Unit Team play?
The Unit Team consists of staff members who provide daily direct patient care by conducting fall risk assessments, planning care for fall prevention, and ensuring that care is performed and documented. In other words, they are responsible for the performance of your set of best practices. In most cases, the Unit Team will include everyone on the unit, such as RN, LPN, CNA, medical staff, pharmacist, physical therapist/occupational therapist, and other staff assigned to a unit on a regular basis.
The types of staff working in your hospital may differ from these. You will need to assign roles appropriate to your staffing configuration. An example of the allocation of roles between nurses, aides, and other staff is shown below. It is important to be clear on what roles have or have not changed and what is permitted in each State's practice acts.
Treating medical provider:
Physical or occupational therapist:
Special attention is required when temporary staff rotate onto the unit. They will not be aware of how care is organized on the unit and what their critical role is in fall prevention. Given how frequently temporary staff work on most hospital units, unit managers should develop plans in advance so that temporary staff can be rapidly oriented to their exact roles on the team. Make sure you have a plan in place for temporary staff and can provide appropriate monitoring and assistance.
Many successful improvement efforts have relied on Unit Champions as critical members of the Unit Team, especially during the implementation process. A Unit Champion is a staff member who serves as the liaison between the Implementation Team and the unit staff. The Unit Champion is someone who is familiar with the program goals, care processes, and outcome data that will be used. He or she is often the initial "go to" person when staff have questions.
The Unit Champion posts results, reports on program progress, and provides updates in staff meetings. He or she helps conduct outcome audits. Most important, the Unit Champion is often the "cheerleader" who encourages staff during the difficult implementation process. A Unit Champion may be anyone who works on the unit, including nurses (RN, LPN) and nurse aides. Ideally, there should be at least one champion per shift to provide guidance to other staff. However, the number of champions should be customized to fit the needs of your hospital.
The role of the Unit Champion can be temporary and only needed for getting the program started. Once practices are routinized, the champion may not be needed. However, maintaining a "go to" person may help with program sustainability and ease introduction of additional changes or modifications.
Another approach that has been used successfully is to have several staff on the unit serve as fall prevention resources without the formal title of Unit Champion. This has occurred when frontline staff have become engaged in and excited about fall prevention, usually as a result of their early involvement in improvement efforts. While this approach may not have the public visibility of a Unit Champion, it brings the benefits of engaging more staff and embedding knowledge of good prevention practices more deeply in each unit. The characteristics of these individuals and their roles would be similar to the Unit Champions during the improvement process, and these people would remain in place after fall prevention activities have become routine.
|Look for these characteristics in your Unit Champions and resource staff:
|Tool 4B, "Staff Roles," and Tool 4A, "Assigning Responsibilities for Using Best Practices," in Tools and Resources may help you define the role of Unit Champions and resource staff.|
4.1.4. How should the fall prevention program be organized at the unit level?
While the definition of team member roles is the first step in determining how the fall prevention program will be carried out, how to organize the work is also key: What are the paths of ongoing communication and reporting, including the lines of oversight and accountability? What documentation is needed and to whom is it submitted? How will fall prevention be integrated with ongoing work processes?
The mapping of current processes and analyses of gaps from best practices that you did earlier (described in section 2.2.2) will help address these questions. The earlier work will help you identify the key points of communication and accountability that need to be addressed and to highlight problem areas that require special attention.
What paths of ongoing communication and reporting will be used?
Communication needs to occur between staff at all levels: within the unit (e.g., between nurses, nurses and aides, nurses and physicians, nurses and other staff) and between unit staff, the Implementation Team, and senior management. Communication around clinical issues related to fall prevention is covered in further detail in section 3. Here, we talk about what kind of communication is needed to ensure that the new work processes decided on by the Implementation Team are carried out as intended. We also discuss how to obtain feedback from unit staff on changes that may be needed to the implementation plan.
A variety of strategies can be used to communicate about how changes that are being implemented are actually going. Unit Champions can present updates on the implementation of new changes at regularly scheduled meetings of the Implementation Team. Alternatively, unit managers can provide updates based on information they gather from their staff. The key aspects are that the communication processes occur regularly and thoroughly with the least amount of time and effort.
How will fall prevention be integrated into ongoing work processes?
Building new fall prevention practices into ongoing work processes is necessary for sustainability. Strategies for building prevention into ongoing processes include:
- Making certain procedures universal so that staff do not have to decide which patients they apply to (such as the universal fall precautions discussed in section 3),
- Integrating communication regarding fall risk into regular communication, such as shift handoffs, and
- Creating visual cues or reminders in physical locations, such as logos indicating elements of the fall risk care plan (e.g., assistance with toileting) above the patient's bed.
|Examples of How Change Can Be Incorporated Into Routine Care
Many hospitals are now using electronic health records, which provide additional opportunities to integrate best practices into the daily routine. For hospitals that have electronic records, questions to consider include:
- What information about fall risk factors is already part of the patient record?
- Are data already in the system that can be used as part of a new process to assess fall risk factors?
- What is the most logical place in the record to collect/organize/assess information about patient fall risk factors and any necessary precautions?
|Suggestions for Building Fall Prevention Into Electronic Documentation Systems
Features that can be added to electronic documentation systems include:
|Working from the process map for fall prevention and gap analysis you developed for your organization in the redesign process (section 2.3), develop your individualized operating rules to specify:
Our focus in this toolkit is primarily on preventing falls at the unit level. However, as you organize the unit work, you should think beyond the unit in two ways. First, consider how information about fall risks is conveyed in handing off patients to other units or when discharging patients. Handoffs are generally weak links in our systems. Important questions to ask regarding handoffs include:
- When patients are transferred from the hospital ward to radiology for a test, is the person doing the transport alerted to the patient's fall risk?
- What is the strategy for handling patients who are admitted through the emergency department because of a fall?
- On discharge, do patients and families have input into the postdischarge care plan? Are they given information about how to prevent falls in the home, and are referrals made for additional services and supports, such as home physical or occupational therapy, as needed?
Second, consider how the interactions of other hospital staff with patients could contribute to the observation and care of patients on the unit. For example, orderlies who transport patients on and off the unit can assist in care by ensuring that their transfer techniques are consistent with standards of practice (go to Tool 3E, "Clinical Pathway for Safe Patient Handling"). Dietary staff who distribute and collect trays can provide information about whether the patient has had poor oral intake, thereby increasing risk for volume depletion. In addition, dietary and environmental staff can report if a patient asks to use the toilet or if patients are sitting in a position that puts them at risk for falling, such as at the edge of a wheelchair.
Once you determine which fall prevention practices (described in section 3) to implement and how to define roles and organize work to carry out those practices at the care level in the units (described in section 4.1), you will need to develop strategies to put the practices into action. In this section, we focus on pilot testing and initial implementation of the new practices. In section 6, we will move to sustaining your improvement efforts.
To guide the changes that will be needed, you should consider four questions:
- How do you manage the change process at the front line?
- How do you pilot test the new practices?
- How do you get staff engaged and excited about fall prevention?
- How can you help staff learn new practices?
4.3.1. How do you manage the change process at the front line?
As highlighted in earlier sections, incorporating the new set of practices will involve changes in the way people do their work, which is often difficult. In some cases the changes will be minor, but in others they will be substantial. Therefore, to make the needed changes:
- Ensure that staff understand their new roles, know why the new roles are important, and have the knowledge and tools to carry out their roles.
- Help reduce resistance to change by ensuring that staff understand the reasons for change and agree that change is needed.
- To help staff accept the new set of practices fully, ensure that they understand that those practices offer promising strategies for providing high-quality care for patients and that such care is a priority for their supervisors.
- Identify and minimize practical barriers to using the new practices, such as inadequate access to supplies or equipment. For example, assistive devices, low beds, and floormats should be stored on or near the unit for easy availability.
- At all levels, engage staff to gain their support and buy-in to the improvement effort and help tailor the practices in fall prevention.
To manage the change process effectively, the Implementation Team will guide, coordinate, and support the implementation effort during the pilot phase and as the new prevention practices are rolled out across the hospital. The Implementation Team will work with the Unit Champions described in section 4.1.3 or with others designated as the unit-level lead for this improvement effort. They will need to work in a variety of areas, discussed below.
Involving staff, clinicians, and middle managers
At the unit level, it will be important to involve not only frontline nurses and support staff but also nurse managers and physicians. In section 1 we discussed the importance of leadership support for improvement efforts. The focus then was on senior leadership, but support of middle managers is also needed. For example, nurse managers and service chiefs should be involved in early discussions about how the new set of practices will be introduced and strongly supported in their units.
Physician involvement is often overlooked in fall prevention but needs to be encouraged. Make sure physicians are aware of best practices in fall prevention and hospital policies and procedures. This is particularly true for aspects of care that physicians may need to be involved in, such as medication changes, activity orders, or physical/occupational therapy referrals.
Monitoring implementation progress
The Implementation Team and Unit Champions should develop a process for ongoing monitoring of implementation progress. Part of the process will be gathering feedback from staff and clinicians. For example, Unit Champions can compile questions and problems from staff to send back to the Implementation Team.
In addition, the monitoring process should include tracking changes in fall rates and care processes to prevent falls, as described in section 5. Results should be communicated to staff and to the Implementation Team. The information loop should be closed by having the Implementation Team report to the unit what it did with the information the unit provided.
Sustaining management support
Above the unit level, the Implementation Team should continue to keep senior leaders and middle managers regularly informed about progress with the fall prevention program to sustain their early support for the improvement effort. These individuals' support will be needed during implementation in multiple ways:
- Leaders and managers are important sources of communication. Their expressed support for improving fall prevention will reinforce its importance and thus increase the impetus among staff to adhere to the new practices.
- Leaders and managers can help remove barriers across departments. While the Implementation Team by design should include all divisions affected by fall prevention, some issues may not be resolved within the Implementation Team but need to be taken to a higher level of authority. This will be particularly important if your organization does not have a strong history of quality improvement that gives staff and managers on the improvement team authority to change procedures as needed.
- Senior leaders may need to authorize resources for the prevention initiatives. In the pilot and early implementation phases, the Implementation Team may need, for example, to negotiate with administration (and unit managers) to secure release time for Unit Champions and for staff training. Management's financial support will be needed, for example, if new equipment (e.g., low beds) is recommended in the program or if a fall prevention campaign needs visibility tools such as posters or buttons. You initially considered resource needs for fall prevention in section 1.6. Consider reviewing this list and updating it if needed..
4.3.2. How do you pilot test the new practices?
In starting the implementation process, many organizations begin the rollout of new practices in one or two units before launching them across the hospital. Pilot testing will allow you to identify and work out any problems in the recommended practices and processes at an early stage and thus refine the program to better fit your hospital before the entire launch. It also can generate early success that will build momentum for later spread across the organization.
Small hospitals may have only a few units, so a formal pilot may not be practical. If so, it is still important to consider a trial period where you get feedback and allow for program refinements. It can bring the same advantages of a more formal pilot in identifying problems and customizing the set of prevention practices to fit your hospital needs early in the implementation process.
To begin the pilot, you should choose one or two units to participate. Different criteria may be applied to select the units. You may identify one unit that was successful with a past improvement project and one that was not so successful. You may use a unit with low fall rates and a unit with high fall rates, or units that present different implementation challenges, such as a medical/surgical unit and a geriatric psychiatry unit.
By selecting several very different units, your Implementation Team can hear from the Unit Champions and staff what they like and any problems they have had implementing the program. Two widely different units will give you a better overall feel for refinement that may be needed and ways to answer staff questions that arise.
You will also need to decide what information you will want to collect and from that decide how long to try out the new set of practices. The pilot test can provide two types of information:
- The items you will collect to judge the pilot's success, such as completing fall risk factor assessments, including fall prevention in care plans, or improving adherence to care plans.
- Feedback from participants on how the new practices are working in terms of, for example, the clarity of what is expected from staff or the impact of the new practices on staff workflow. Section 5 provides tools that will help in measuring care processes and outcomes.
You should use information from the pilot to change the fall prevention program to meet your hospital's needs and to change the ways the program is introduced to staff. You also can use the pilot to identify additional staff barriers to change.
Rather than designing the pilot like a research project where the intervention—in this case the new fall prevention practices—is held constant for the duration of the test period, consider conducting a formative pilot in which changes are made as needed during the pilot to maximize the likelihood of success. In this case, pilot information will be provided to the participating units, Unit Champions, and the Implementation Team on a regular basis throughout the pilot period, rather than simply after it has been completed. Minor modifications can be made along the way and their impact followed within the pilot phase.
4.3.3. How do you get staff engaged and excited about fall prevention?
Engaging the buy-in and ongoing participation of staff members is particularly important for staff who are involved in hands-on care and whose involvement will be needed to achieve the improvement objectives. Each unit has its own culture; some people will be willing to try something new and others will have difficulty or be unwilling to make any changes. To have any program succeed, unit staff need to have input and be able to make suggestions on how to individualize the program for their unit.
In preparation for the initial rollout or pilot testing on each unit, the Implementation Team or Unit Champions should meet with unit staff on all shifts. They should review the newly defined roles and responsibilities and work with staff to determine how to adjust roles and paths for communication and reporting among staff on their unit. They also should discuss how to address barriers to adherence.
This process can take place with a unit-level improvement team or with the entire staff, such as at a regular staff meeting. A challenge in facilitating these discussions will be to distinguish between constructive tailoring that will enhance adherence to the new set of practices and weakening of the new practices to reflect reluctance to change or failure to accept them.
Even with involvement in tailoring the changes to their unit or position, some clinicians and staff may be reluctant to use the new set of practices. Strategies for dealing with such reluctance will depend on a number of factors, including the stage of implementation, the positions of and number of people resisting, and the reasons for and strength of resistance.
If reluctance, or active resistance, is localized to specific parts of the hospital or to specific individuals, you may decide not to include those units or individuals in the early implementation. Focus instead on the units and people with the greatest interest and highest likelihood of success. Their early success may convince others that the new set of practices is worth using. Or as implementation advances and the new practices become the norm, peer pressure may spur resisters to change their minds.
Including fall prevention in staff performance evaluations can formalize the new practices as the norm and enhance commitment. If resistance during early implementation is widespread, you will need to understand why. Then you can either redesign the set of practices or implementation strategy to accommodate the resisters' concerns or reconsider your earlier conclusion that the hospital is ready for this change. If the latter, you may want to continue to use the new program in volunteer units until you can build a successful case for hospitalwide use.
|Examples of Strategies That May Help To Reduce Staff Resistance
|Examples of methods and strategies to increase staff engagement can be found in a recent critical care nursing journal article.* Key points from this article include:
Once the initial pilot test has been completed, you will have information about areas in which education is required to enhance staff knowledge. This aspect, while valuable, is not enough to change practices. Staff members also need help figuring out how to integrate their new knowledge into their existing practice and how to replace existing practices and skills that may be less effective with others that are more effective. Thus, a variety of methods for sharing information about new practices is needed.
Adult learning theory suggests that adults learn best through methods that build on their own experiences. Since individuals have different learning styles and are at different levels of practice proficiency, a variety of educational approaches is best, including, but not limited to, the following:
- Didactic methods can include a variety of formats, such as lectures, interactive presentations, online lessons, case study analysis, listserv discussion, and grand rounds talks.
- Care practice simulations, expert practitioner observation of care delivery, and competency validation also can enhance learning.
- Clinical bedside rounds and patient case review are excellent ways to translate abstract knowledge into behavior changes.
Any and all plans for new or changed staff education should be worked out in close collaboration with your existing content experts on fall prevention. As discussed in section 6, learning will need to be supported on an ongoing basis, both as refreshers for existing staff and as training for new staff.
|To assess current staff education practices, complete the checklist found in Tools and Resources (Tool 4C, "Assessing Staff Education and Training").|
|The checklist for implementing best practices can be found in Tools and Resources (Tool 4D, "Implementing Best Practices Checklist").|