Preventing Falls in Hospitals

Tool 2C: Current Process Analysis

Word Version [ Microsoft Word file - 30.33 KB]

Background: Before beginning a quality improvement initiative, you need to understand your current methods. This tool can be used to describe key processes in your organization where fall prevention activities could or should happen.

Reference: Adapted from: Quality Partners of Rhode Island. QI Worksheet E, Current Process Analysis. Available at:

How to use this tool:

  • Identify who will conduct the mapping and who will be on the mapping team. The mapping team should include at least two frontline staff on the Implementation Team and at least one person who has experience with process maps. Try to use the same team members if more than one process is mapped.
  • Have the Implementation Team identify and define every step in the current process for fall prevention.
  • Define a beginning, an end, and a methodology for all of the processes to be mapped. For example, some processes are mapped through the method of direct observation of the process taking place, while others can be mapped by knowledgeable stakeholders talking through and documenting each step in the process.
  • When defining a process, think about staff roles in the process, the tools or materials staff use, and the flow of activities.
  • Everything is a process, whether it is admitting a patient, serving meals, assessing pain, or managing a nursing unit. Identify key processes involving fall prevention. The goal of defining a process is to hone in on patient safety vulnerabilities and potential failures in the current process.
  • Examples of processes might include initial fall risk factor assessments (e.g., when does it occur, who does it, what happens if a patient is found to have risk factors) or postfall management.

Determine if there are any gaps and problems in your current processes, and use the results of this analysis to systematically change these processes. 

Process Analysis Procedures

  • Take time to brainstorm and listen to every team member.
  • Make sure the process is understood and documented.
  • Make each step in the process very specific.
  • Use one post-it note, index card, or scrap piece of paper for each step in the process.
  • Lay out each step, move steps, and add and remove steps until the team agrees on the final process.
  • If a process does not exist (for example, there is no process to assess fall risk factors upon admission and readmission), identify the related processes (for example, the process for admission and readmission).
  • If the process is different for different shifts, identify each individual process.

Example: Process for Making Buttered Toast

Step     Definition:

  1. Check to see if there is bread, butter, knife, and toaster.
  2. If supplies are missing, go to the store and purchase them.
  3. Check to see if the toaster is plugged in. If not, plug in the toaster.
  4. Check setting on toaster. Adjust to darker or lighter as preferred.
  5. Put a slice of bread in toaster.
  6. Turn toaster on.
  7. Wait for bread to toast.
  8. When toast is ready, remove from toaster and put on plate.
  9. Use knife to cut pat of butter.
  10. Use knife to spread butter on toast.


Identify the steps of your defined process:
  • Press people for details.
  • At the end of the gap analysis, compile the results in a document that displays each step so that team members have the map of the current process in front of them during the team discussion (Step 2).
Hold team discussion.

Evaluate your current process as you define it:

  • What policies and procedures do we have in place for this process?
  • What forms do we use?
  • How does our physical environment support or hinder this process?
  • Which staff are involved in this process?
  • Which parts of this process do not work?
  • Do we duplicate any work unnecessarily? Where?
  • Are there any delays in the process? Why?
Continue asking questions that are important in learning more about this process.

Return to Roadmap

Page last reviewed January 2013
Page originally created January 2013
Internet Citation: Tool 2C: Current Process Analysis. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD.