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:
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.
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.
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:
|Key elements for a thriving Sustainability Team are summarized in Tools and Resources (Tool 6A, "Sustainability Tool").|
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:
Key points from this article include:
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.
Strategies the implementation team could use to reinforce the desired results of the mobility program include:
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.