Improving Patient Safety in Long-Term Care Facilities

Module 3. Falls Prevention

Instructor Guide

This Instructor's Guide describes how to use the materials in the companion Student Workbook as a teaching session and also how to apply a quality improvement project for the topic of falls prevention and management.


Principal Message

The single most important message your audience should come away with is that they can help reduce the number of falls and fall-related injuries at their nursing center. Nursing staff should know the risk factors contributing to falls and ways to prevent them. In addition, they should be able to manage injuries that result from falls.

Staff should understand what it means to work in a safe environment, where nursing staff can work together as a team and share information openly. It also means they understand that keeping residents safe, and not worrying about who might be to blame when things go wrong, is the most important consideration. Participants should experience the setting of your teaching as an example of a safe environment, where information is freely shared and concerns are openly reported and supportively addressed.

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Principal Audiences

This training is geared towards licensed nurses (RNs/LPNs/LVNs) and nursing assistants. It is designed to be accessible and relevant to all these care providers, so you can teach your participants all together, mixing the professional roles.

Teaching the different professions together is important because it will, in and of itself, likely improve teamwork by allowing each profession to understand the other better. For instance, anecdotal research suggests that nursing assistants feel that licensed nurses rarely read their notes. Learning together presents an opportunity for nursing assistants to understand more about what licensed nurses need to see in a nursing assistant's note, and it allows licensed nurses to understand that it is important to read the notes and to let nursing assistants know that they do so.

If the learning culture of your audience suggests that staff from different professions cannot learn together, you can separate your participants into different sessions according to their professional roles.

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Workbook Content Overview

Clinical Content

Falls are serious, unwanted events (negative effects on a resident's health) that happen in both hospitals and long-term nursing centers. They can lead to medical complications or even death.

This module reviews the problem of falls in nursing settings. Risk factors are identified, and ways to prevent injury are discussed.

Content by Session

This module is designed for presentation in two sessions. The first session starts by describing what it takes to make a safe work environment in which sharing of events in a blame-free way allows supportive learning. It goes on to define and explain what a fall is, noting that falls should be distinguished from sudden medical events that can cause what looks like or also involves a fall, such as a stroke or seizure. It also describes risk factors for falls.

The second session describes how to do an assessment of fall risks for residents and how to respond to a fall or near fall.

Your teaching goals for both sessions of the module are to:

  • Ensure that participants understand how a safe environment means open reporting and supportive teamwork to minimize injurious falls.
  • Develop participants' knowledge and skills in preventing falls and fall-related injuries.

The module materials can be used flexibly to fit a range of session lengths. Selecting materials to suit a 30-minute single session, for instance, is quite possible. However, this module is designed to be a 2-hour session.

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Objectives of the Session

Objectives are separated into knowledge and corresponding performance objectives. Slides are provided (go to Appendix 3-A), but they do not appear in the Student Workbook. You can provide these at the start of the session and even have them up on a flip chart or screen that stays on the side of the room during the session, or return to them at the end of the session to give participants a sense that they are following your road map. It is often best to select one, two, or three objectives and leave the others aside. In teaching things that you want participants to really take in and use in practice, often 'less is more;' people can take in and integrate the new material in a useable way. You can remove unwanted objectives on the slide or highlight the ones you will focus on.

Knowledge Objectives for Participants

For all:

  • Understand why falls are an important safety issue.
  • Understand the risk factors for falls.
  • Understand which residents are at high risk of falling.
  • Understand how falls can be prevented.
  • Understand how nursing assistants and licensed nurses can work together to prevent falls.

Performance Objectives for Participants

For all:

  • Describe nursing interventions to prevent falls, either:
    • Initiated by a nursing assistant.
    • Initiated by a licensed nurse.
  • Use particular interventions for particular risk factors.
  • Work as a member of a nursing team to:
    • Choose intervention(s) for a particular case.
    • Assess whether an intervention is effective.

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Preparing for a Session

1. Assess the Needs of Your Audience

These training materials are meant to be used as a complete package. However, you may tailor them to the needs of participants and current practice at their nursing center. To determine needs, you may use a survey or talk to individuals familiar with the nursing center. Whether you choose to use all or some of the material in the Student Workbook, decide on a focused goal for teaching. It is better for participants to learn and remember a few important pieces of new information than to feel overwhelmed by many new ideas.

Consider the language level that will best suit your audience. If you use technical medical terms, be sure to explain the meaning of the terms. If your audience uses English as a second language, speak clearly and not too quickly.

2. Consider Your Teaching Method(s)

Most instructors find that a combination of methods—lecture and interactive—works best. Consider using a selection of these teaching methods:

  • Lecture with slides.
  • Whole group discussion.
  • Break-out group discussion.
  • Case discussion.
  • Role play.

Suggestions for ways to use these methods can be found in the "Recommended Teaching Methods" section of this module.

3. Presentation Timing

The suggested timing for each portion of this 2-hour module is:

Activity Time
Introduction of Instructor, Topic, and Objectives 5 minutes
Pre-test 5 minutes
Case Discussion 10 minutes
Presentation 1, Interactive Lecture 20 minutes
Case and "Critical Reflection" Discussion 15 minutes
Break 5 minutes
Presentation 2, Interactive Lecture 18 minutes
Case Discussion and Role Play (2 scenarios) 20 minutes
Debrief on Teaching Methods 5 minutes
Key Take-Home points 5 minutes
Post-test. 5 minutes
  Total: 115 minutes

Although this is a 2-hour module, you can teach it in two 1-hour blocks. You can also select material within the module to make a 30-minute or a 45-minute session, or two 30-minute sessions within a 1-hour slot. This flexibility is important, as some nursing centers might not have adequate nursing coverage for a 2-hour session.

4. Slides

The Student Workbook text is not meant to be used as a prepared speech. It assumes that you know the subject and offers material you may want to use. The suggested slides (Appendix 3-A) can be used to trigger your presentation. If you decide to do that, you will find it useful to practice speaking with them.

5. Overview of Effective Instruction for Adult Learners

Adult learning involves change—in knowledge, behavior, and skills.

This module aims to help participants know the risk factors contributing to falls, ways to prevent falls, and how to manage injuries that result from falls.

Adults are usually most motivated to learn when:

  • They see the subject as directly related to their own needs and goals.
  • They see ways for their learning to be applied to their own work settings.
  • They are responsible for their own learning.
  • Their knowledge and skills are appreciated.
  • "Mistakes" are seen as chances to learn.
  • Practical, hands-on experience is part of the instruction.

Adults take in new information more quickly and remember it better when it relates to their own experience. Structure your session to draw on what participants already know and what they want to learn. Make sure everyone feels that they have something to contribute.

Teaching methods such as interactive lecture, case discussion, and role play help lead adults to make changes in the workplace. A good way to get your group moving in this direction is by starting with a case for discussion. If the case reflects a situation that is familiar to participants, and includes a problem they want to solve, you will have a "teachable moment."

Interactive Lecture

With this method you present the material, using questions and answers, slides, and other visual aids.

Case Discussion

The case tells a story. It involves situations like those participants face at work. You lead a discussion that brings in what they know and how they might handle the situation. You will want to be sure that different ideas are heard and see if anyone changes their mind. You will find a sample case in the "Giving Your Presentation" section, below.

Role Play

"Learning through acting" gives participants a chance to use what they know and practice something new in a real-world setting. It can help them see a situation from different points of view. It also helps develop communication skills.

Writing It Down

With all these techniques, it is useful to note participants' ideas and questions—a flip chart works well. This helps keep participants thinking and engaged. You can keep a "parking lot" list of thoughts that may not be on point at the moment, but should be kept in mind when you sum up the session.

More information on how to teach this material is below, in the "Giving Your Presentation" section.

6. Preparing a Handout for Participants

These training materials are meant to be used as a complete package. However, you can choose to use only the parts you think are most relevant for your particular audience and their nursing center. The materials in the Student Workbook may be reproduced and provided to participants. The case is included in the Student Workbook.

7. Learning Settings that Work for this Module

Think ahead about the kind of setting that will be available for this training and will best allow your targeted group to participate in the training. You also will want to consider work shifts and how your session can fit with in-service training requirements or other options. It helps if your session meets some of the nursing center's requirements for staff training. Provide refreshments if you can—that tends to increase attendance. Post announcements ahead of time so that people know when and where your session is going to happen. You might have a leader introduce the session to show that management believes the training is important.

8. Using Pre- and Post-Tests

Pre- and post-tests (go to Appendix 3-B) provide real-time feedback on how well the training session worked. The pre-test sets a baseline of what participants knew about the topic before the session; this information can be compared to the results of the post-test to answer the questions, "What changed from the beginning of the session to the end? Did participants learn what we wanted them to learn?"

9. Equipment

You will need equipment that allows you to display slides and also record discussion points and questions from participants. You may use:

  • PowerPoint slides.
  • Slide projector and screen.
  • Flip chart.
  • Overhead projector with transparencies.

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Giving Your Presentation

  1. Introduce yourself and explain the purpose of the training.
  2. Hand out the pre-tests. Explain that pre- and post-tests help participants evaluate themselves and help you evaluate the course. Have participants complete the pre-test.
  3. Introduce the topic and review session objectives (using slides found in Appendix 3-A).
  4. Present the material.

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Recommended Teaching Methods

For this module, a mix of teaching methods may be the best—some interactive lecture, some case discussion, and some role play.

Interactive Lecture

The "stand-up" lecture works well when the topic is something participants care about and when the speaker is engaging. It is best used when a large amount of information needs to be delivered to a silent audience.

In an "interactive lecture" you still speak most of the time and control the subject being addressed, but the audience participates in different ways—asking or answering questions, giving examples from their experience, expressing opinions.

Like a story, any lecture—regardless of length—has a beginning (the introduction), a middle (the body), and an end (the summary). Each of these serves a different purpose.

Introduction: establishes the purpose of the lecture. The introduction states overall goals and specific objectives and should include an overview of the whole lecture. You are aiming to get participants interested and make them aware of expectations for the session.

Body: includes the material needed to meet the objectives stated in the introduction. Your session will be most effective if you:

  • Grab participants' attention in the first few minutes.
  • Involve them in fine-tuning the focus of learning.
  • Plan a change of pace every 8-10 minutes during a lecture.
  • Give participants a chance to reflect.
  • Use visual aids.
  • Give participants a chance to share experiences.

Summary: includes a recap of the material presented in the body of the lecture. It may also include an opportunity for participants' questions and feedback.

Case Discussion

Most instructors prefer to use the case provided in this module. A clinically experienced instructor who is also a seasoned teacher may also invite participants to contribute relevant cases they have encountered. A new instructor, however, may prefer to keep the focus on a familiar case.

Case Study

Mr. P is an 84-year-old man who has been a resident at the nursing center for the last 2 years. He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. Until recently he shared a room at the nursing center with his wife, but she passed away earlier this year. Since that time, he has been more depressed and has had difficulty sleeping. On admission to the nursing center, he used a walker to get around, but now he mostly uses a wheelchair; he is less able to do his own toileting and grooming. His safety awareness is poor, and he has had many falls. Many of the falls have happened at night after his private duty caregiver has gone home.

What are his risk factors for falling? How might you, as his nursing assistant, help protect him from having an injurious fall during the night?

Once the case has been presented, pause and invite participants to comment.

Questions to get the discussion going and draw on prior knowledge might be of the "survey" type:

  • Have any of you seen a resident fall?
  • How often would you say this happens in your nursing center?
  • Does your nursing center have rules about what you are you supposed to do when a resident falls? If so, can you give an example of one of those rules?

Questions you could ask to reinforce the knowledge you are sharing might be:

  • Can you describe the physical conditions affecting Mr. P?
  • Can you describe the emotional conditions affecting Mr. P?
  • Mr. P seems to have several risk factors for falls. What do you think they are?

You can then encourage critical thinking and communication with questions such as:

  • How could Mr. P's safety awareness be raised?
  • How could staffing be organized so that Mr. P's needs at night are met?
  • What factors in the environment could be changed so that Mr. P is less likely to fall?
  • How do you think communication should work between private duty caregivers and nursing center staff?

You might ask participants to brainstorm safety ideas for residents with a history of falls.

Keep in mind that you are trying to get participants to think in terms of teamwork rather than blame.

Try to get them to talk with each other, not just to you. Have them discuss a topic in pairs or in groups of three. This method makes it easier for a shy person to be heard, as the less shy member of the pair or team can speak up for both or all of them.

If the number of participants is small, case discussion may be led with the whole group. Larger groups may be broken up into smaller ones, with each taking one or two questions and then reporting out to the whole group. You may also wish to divide participants into groups according to what they do (i.e., licensed nurses, nursing assistants, occupational and physical therapists, etc.).

Role Play

This technique has participants take on roles in a clinical interaction. There is no written script, and the "actors" don't have to memorize anything.

There are five parts to this technique.

Set-up: ask participants about their previous experiences with role play. Explain the goals of this exercise and relate them to the key learning objectives. Make sure everyone is familiar with the overview of the case. Only the "actors," however, will know the details of their roles. It may be helpful to provide the description of the role play to those who are not participating as actors in the role play.

Then go over some guidelines:

  • Anything that comes up is confidential.
  • This is a safe place. Actors should not be afraid to take risks.
  • Feel free to be spontaneous.

Assign the roles: you may have actors play a role similar to the one they have in their real jobs; or you might encourage them to try out a new one. A licensed nurse, for example, could take the part of a resident, or a nursing assistant could act as a licensed nurse. Involve as many people as possible in the role play. Because role play requires participants to be somewhat emotionally open, they may feel anxious or resist being an actor. Your own positive attitude and a light touch will help. Any participants who are not assigned to a role should be asked to be observers.

Conduct the role play: participants act out their roles in the "scenarios" you provide (examples below), based on the case. Try not to interrupt the role play while it is running; just let the interactions flow naturally.

Before each scenario, explain how much time it will take, and that it will be followed by discussion. It should take only 2-3 minutes, followed by perhaps 5 minutes of discussion.

Don't let the role play go on for too long—most of the learning happens in the first few minutes. If actors seem too carried away by their roles, remind them to keep it simple.

Scenario 1. Two roles: A licensed nurse and a nursing assistant. It is the nursing assistant's first time on this floor. When she stops by Mr. P's room for a routine check after dinner, she finds him at the bathroom door, trying to get out of his wheelchair. He seems irritable and does not want the nursing assistant to help him.

Tell the role players to simulate the interaction between the nursing assistant and the licensed nurse, making it clear when the interaction is happening and in what setting (e.g., on the phone as soon as possible, at change of shift, etc.). Tell them their goals are to: (1) get all the information across, (2) communicate about the situation in a timely fashion, and (3) be able to push if the message does not seem to be getting across.

Scenario 2. Three roles: Mr. P's son Paul, a licensed nurse, and a nursing assistant. Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury. When the nursing assistant comes by to take Mr. P's temperature, Paul asks about his father's condition and the fall. Paul asks that his father be put into restraints so that he does not get hurt again.

Tell the role players to simulate the interaction with the goals of: (1) helping Paul to understand that the fall was without injury because of precautions taken, and that his father would be unhappy in restraints and less safe; and (2) explaining to Paul what is being done to limit injury from falls.

Discuss the role play: discuss the issues that came up in the role play. Everyone's input should be included. After each scenario is played out, ask the actors: What went well? What did not go well? What would they do differently next time? How did it feel to say____? How did it feel to hear____? Ask observers for their opinions about what the desired outcome was in each situation and how they might have handled the situation differently.

Conclude the role play: encourage a round of applause as the participants return to "out of role." Summarize the major themes and issues. Consider with the group how to apply the role play to real life clinical situations. Emphasize what was learned during the role play.

Debrief About the Teaching Method

  • Ask participants what methods they think you used. Get their thoughts on what worked and what could be done better.
  • Listen and thank them for their thoughts.

Review Key Take-Home Points

  • Promote a safe environment based on teamwork and thinking about how the system of care works and how it can be improved and not about blame.
  • Educate the entire staff about the importance of falls, risk factors for residents, and methods of prevention.
  • Use appropriate risk-assessment and reporting tools.


Thank your participants for attending. Let them know that you enjoyed being with them. Hand out the post-tests. Emphasize how important it is to complete the post-tests because they can get feedback on what they have learned (based on their answers to the pre- and post-test questions). Tell participants that you will provide the correct answers and rationale for the tests after they are done. Be sure to stress that the post-test is anonymous.

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Translating the Teaching into Practice

It is often hard to get what is taught in a classroom or in-service learning session translated into action as part of resident care. Even if the teaching has gone well and the learning was taken in and appreciated, it can be hard to put the new learning into practice. There are many possible barriers. For instance, the system of care may not accommodate the new practice, or the culture of care may not accept the change, or the leadership may not be aware of the new learning and so may not make room for it.

Following up after a teaching session with a quality improvement project in which the new learning is put into practice by the whole team can help a lot. Quality improvement projects use a step-by-step approach to improving care by taking a long, hard look at what needs to be done; and by starting out with a small change, watching it, adding to it, and continuing on in this fashion until the job is done. It has a whole method to it, and the method is described in the "Quality Improvement" section.

Quality improvement methods often include a teaching step. This module can be the teaching material for that step. If the quality improvement project is to improve nursing assistants' and licensed nurses' understanding of ways to prevent and manage falls, then this module is perfect for the teaching part of the project.

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Quality Improvement

"Quality Improvement" (QI) is an approach that may be used by nursing staff and managers to improve quality and safety in patient care. It has three main objectives, which are to:

  • Gain knowledge and skills to understand systems of care and minimize adverse outcomes.
  • Apply methods to identify, measure, and analyze problems with care delivery.
  • Act on the results of data collection and analysis to improve both individual care delivery and systems of care delivery.

QI is a team approach, involving everyone in thinking about innovation and recognizing that the key to improvement is the people who care for patients. It is not about individual rewards and punishments, but rather it relies on measurement to improve the center's performance as a whole.

At the core of QI is the "Plan-Do-Study-Act (PDSA) Cycle," based on trial and error over time.

  • Plan: Identify a problem and design a change to address it.
  • Do: Implement a small change.
  • Study: Measure and analyze the effects of the change.
  • Act: Take action based on the results of analysis, such as trying another change, formally implementing a change, or extending an implementation more broadly.

When you engage in a QI project, you will be using information/data that you have on current practices at your site to develop goals based on both best practices and realistic expectations.

The five phases of the QI process are outlined here.5

1. Project Initiation Phase

Decide on the Area of Work that Needs Improvement

In this example, we focus on risk factors for falls. Most likely, there is already a process at the center to get to this point. Still, it is helpful when starting the project to make sure everyone believes in its importance. Collect data to support your assumption that there is a problem and establish a baseline for measuring improvement.

Form Teams

Leadership teams must include one or a few people with enough institutional authority to help get the resources that the project team needs.

For this project, the Director of Nursing, the Quality Improvement Officer, the center's overall Director, and/or the Chief Operating Officer would be potentially good choices.

Project teams must:

  • Have basic knowledge of the problem.
  • Represent all parts of the process and different levels of the organization.
  • Have at least one member trained in QI.
  • Recognize that good ideas can come from anyone.

The ideal team size is five to nine people. Additional temporary members with special areas of expertise can be invited to particular meetings as needed.

For an improvement project focused on communication of changes, the following project team members are one example of a good team:

  • Registered nurse.
  • Two nursing assistants.
  • Director of nursing.
  • Education director.
  • Geriatrician.

Write an Aim or Mission Statement that is "SMART"

  • Specific.
  • Measurable.
  • Appropriate.
  • Result-oriented.
  • Time-scheduled.

The aim should include a "stretch" goal that may be hard to reach but is achievable—for example: To decrease the rate of resident falls by 50 percent in 12 months.

Consider Appropriate Measures

Examples of measurement (data) include a "process" measure like compliance rates for wearing ID badges with the SBAR or CUS6 acronym spelled out on the back, documented nursing notes in the chart on reports of change, in a resident's condition or an "outcome measure" like reported use rates for SBAR and for CUS.

To show improvement, you should be able to plot the variable being measured on a run chart (a graph that displays observed data in a time sequence).

2. Identifying the Problem

Identify the Problem
  • The problem and its extent (i.e., what are the existing barriers to recognizing risk factors for falls?).
  • Changes that can be made that are expected to result in improvement (i.e., what might reduce the barriers to recognizing risk factors for falls and how?).
  • How the effects of the changes will be measured (i.e., select the measures that you will use to assess change over time in nursing assistants' abilities to recognize risk factors for falls).
Plan for Data Collection and Analysis

Tools that can help in data collection and analysis include process flow charts, brainstorming, cause and effect diagrams, and consumer focus groups.7

3. Intervention Phase

Get Consensus

Get team consensus on priorities and changes most likely to result in improvement and then decide on an intervention.

Remember Culture and Teaching, as well as Protocols

Many interventions focus on what is done; for instance, changing or adding a protocol. These are good, but they often don't work as well as they could unless they go hand-in-hand with changes in culture to appreciate the importance of the new protocol. The best interventions tend to address culture with team meetings and other educational or inspirational materials at the same time that the new protocol is added. Usually, culture change includes implementing and disseminating some core teaching.

Conduct PDSA (Plan, Do, Study, Act) Cycles

The cycle begins with a plan and ends with an action based on learning gained. It should specify who, what, when, and where. The end of each cycle leads directly to the start of the next one.

  • Try a change, e.g., provide a new I.D. badge with SBAR and CUS on the back, as well as a 1-hour, online educational session to nurses on a specific ward.
  • Observe consequences by using the selected measures.
  • Learn from consequences, e.g., some used SBAR and CUS, but others did not. You discover that those who used the tools had taken the online learning, and the others had not.
  • Try a change, e.g., in-service time is given for all staff to complete the online education, then run another PDSA cycle.

The way you document observations may be simple, such as counting and recording on a tally sheet; or it may be more complex, such as using sophisticated tools for data analysis.

If the data do not support the intervention, they may not be appropriate. Look at the data for clues about what to change and run another PDSA cycle. When you have finally arrived at a sustained change of the kind you intended, that final version of the intervention can be implemented on a larger scale.

4. Implementation and Impact

Implement the Change

This means making it a permanent part of normal business throughout the unit or setting where you work. It may mean applying the intervention throughout the nursing center, for instance. In this case, it would probably mean ensuring that all nurses and nursing assistants take the online training and receive badges with SBAR and CUS written on the back.

Relevant support processes have to be implemented at the same time. For instance, the rollout of education will need to be supported with suitable in-service learning time.

Measure the Impact of the Change

To provide evidence that the intervention resulted in improvement in all places it was implemented, you will need to collect, analyze, and display the data. For example, you might create a chart showing changes in the number of times nursing assistants recognize that a resident is doing something that puts him or her at risk of falling, unit by unit, in the whole nursing center. You will be able to choose your measure from the experience you gained in the Intervention Phase (go to item 3, above).

5. Sustaining Improvement

The step in QI that fails most often is sustaining the improvement. When the project is done, even if it has been successful, if it is not monitored and no one is assigned to make sure the new standards are kept up, it will probably fade away.

Mechanisms for sustaining change include:

  • Standardization, ensuring that new methods are implemented consistently over time.
  • Documentation of the project from planning through testing, implementation, and followup.
  • Indefinite periodic measurement, e.g., of reported SBAR and CUS use rates, and review to ensure that the change becomes routine practice. The measure chosen for this is called a quality indicator, and it usually is easy to establish (for instance, something that is part of the Minimum Data Set or some other set of data that is always collected) and part of what a senior person reviews regularly.
  • Staff training and education, geared to the type of change proposed, the people who will be asked to implement it, and the skill level and work experience of the target group.

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Applying QI to Improving Falls Prevention and Management

Starting the Improvement Effort

First you will generate and look at relevant data on falls prevention and management in your area, probably with some of your lead team members. For instance, you might look at relevant Minimum Data Set8 (MDS) numbers from your center and nationally. Then you will ask questions and discuss how this state of affairs stacks up against other institutional priorities. When you have decided that this is the area you want to work on, you will form your teams—you will have a leadership team of one or a few people and a project team of five to nine. The project team will write a mission statement and select measures that the leadership team will review, adjust as needed, and approve.

Then the project team will decide which problem to address in order to help prevent falls. Whatever the intervention, it will likely be essential to enhance the culture of awareness and the importance placed on the topic. That is usually where the teaching module comes in. The project team will decide what area to work in first and will identify which process or processes to change. Next, the people in that unit will be trained about the topic area.

The Intervention

In the case of falls prevention and management, the primary intervention may be teaching this module, but it is likely that there will be a counterpart change in standard operations. For instance, daily rounds may add a specific question for every resident: What is [resident name] falls risk and management plan? Or the change may involve adding this question to the format used by nursing assistants in their written reports. Each QI effort may have its own intervention to enhance falls prevention and management.

Including Teaching for Culture Change in the Effort

Finding the right person to teach the module is important. Someone that the participants will look up to and respect for their knowledge of the area is essential. Finding a person who teaches well is also very important and not always easy to identify. The person can be a lead nurse or other clinician, a QI officer, or a special guest teacher.

Plan-Do-Study-Act (PDSA) Cycles

When the teaching is done and the new protocol is starting, someone on the project team will be assigned to collect and review the data. They will look at the data, decide what seems to be working and what seems to not be working, adjust the protocol, let the staff know, and try again. They will continue in this manner until things seem to be where they should be for a sustained period of time.

Implementation and Impact

Next, the protocol and education will be rolled out throughout the relevant area—say, the whole nursing center. A small number of key measures will be collected that the center can monitor to know how well the implementation worked. For falls prevention and management, MDS data may be sufficient or perhaps another measure will be added, such as the rate of performing documented falls risk assessments and formulation of management plans for residents.

Concluding the Improvement Effort

Finally, a routine measure—such as the rate of documented nursing assistant reports of falls risk assessments and management plans—should be chosen as a quality indicator. The leadership team then needs to ensure that the quality indicator is routinely collected and reviewed by a responsible member of the center to ensure that the improvement is sustained over time and, if it tapers off over time, that attention to the problem is renewed.

5. For more detailed information on QI and measurement tools, please see The Patient Safety Education Project (PSEP), Module 9: Methods for Improving Safety, which can be found at Accessed January 23, 2012.
6. SBAR = Situation, Background, Assessment, Recommendation; CUS = Concerned, Uncomfortable, Safety.
7. Such tools are readily accessible at: (Easy Guide to Clinical Practice Improvement: A Guide for Healthcare Professionals. New South Wales, Australia: New South Wales Department of Health; 2002).
8. Go to the MDS Basic Assessment Tracking Form, available at Accessed January 23, 2012.

Page last reviewed October 2014
Page originally created June 2012
Internet Citation: Module 3. Falls Prevention. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
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