Executive Style Summary

Posted: January 5th, 2023

Executive Style Summary

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Executive Style Summary

The proposed practice changes are intended to reduce patient fall incidents at a Level II trauma center in a rural teaching community facility serving 350 patients daily. The specific elements of the proposed practice changes include hourly rounds in high fall-risk units, post-fall huddles, team training and a change in organizational culture at the facility. This proposal follows the findings of a quality and safety gap analysis that was conducted at the trauma facility, which is part of nine healthcare establishments delivering integrated care for clients of all ages in need of emergency, surgical, oncology, palliative, and geriatric care. The findings indicated that the community Level II trauma facility had experienced increased patient falls despite instituting collaborated efforts to avoid falls among at-risk patients. Although the facility had employed an electronic scoring rubric or protocol through a bedside sitter, it had seen the falls cases reach 5.01 patients per day. This figure was much higher than the benchmarked rate of 3.4 falls per 100 patient days, according to Patient Safety Network (2019).  The analysis revealed that the patient fall rate at the facility had surpassed the standards provided by the National Database of Nursing Quality Indicators (NDNQI) by over 30% in two units therein. Therefore, there was an urgent need to formulate and implement practice change interventions that would reverse this worrisome trend.

Key Quality and Safety Outcomes

Patient falls were a leading cause of unsafe incidents reported in healthcare facilities and were considered as hospital-acquired conditions by the Centers for Medicare and Medicaid Services (CMS) because they were avoidable (Patient Safety Network, 2019). The seriousness of these incidents needed attention because they were the primary cause of patient injuries, which undermined the quality of life for the patients and placed a heavy financial burden on the resource-strapped healthcare facilities. These undesirable outcomes were considered higher in specialized care settings such as the one found at the rural teaching community Level II trauma facility for which the practice changes are proposed. 

Strategic Value of Specific Outcome Measures to the Organization

The proposed practice changes are expected to deliver strategic value to the rural teaching community Level II trauma facility. Specific strategic value improvements include reducing patient injuries. The value of reduced patient injuries would be the cost-saving outcomes to the Level II trauma facility. This would emanate from reduced extended patient stay at the facility, saving on the medications and human resources expended when caring for these patients. Consequently, this would free scarce resources for deployment to other critical services at the facility, thus enhancing the efficient use of financial and human resources. Similarly, the improved quality of life of the patients at the hospital would add value to the Level II trauma facility by improving the hospital’s reputation as a provider of high-quality care. Reducing health complications associated with reduced falls would add value to the facility by lowering the workload of the healthcare personnel. This would ensure that the healthcare team members are not overly fatigued and therefore ready to attend to other unavoidable critical health issues diligently without errors. The speedy recovery of trauma patients is another outcome that would add value to the trauma facility. The facility would benefit from the improved reputation from the satisfied patients and their families. In turn, the facility would be highly-sought after by patients for its provision of cost-effective and high-quality healthcare services. This would increase the revenues earned by the facility, in the long-term.

Relationship between the Facility’s Systematic Problem and the Proposed Practice Changes

The specific proposed practice changes expected to deliver these desirable outcomes are formulated from the evidence-based Patient-Centered Fall Prevention Toolkit, the Fall TIPS (Tailoring Interventions for Patient Safety) established by the Joint Commission (Duckworth et al., 2019). They include, firstly, placing place a patient at increased fall risk on a fall protocol comprising a yellow recognition band, slipper socks, yellow light on a call light panel outside their door, support them when out of their beds, and implement chair and bed alarms. This is expected to identify the vulnerable patients and promoting their surveillance by the nurses. This proposal is informed by the lapses in monitoring patient behavior while in bed or leaving the bed. It has been observed that some patients leave their beds unnoticed by the caregivers because of improper use of monitoring and alerting devices. Patients at the highest risk were not categorized as such, and therefore, fall prevention protocols were not followed for those at the highest risk of falling, especially the elderly patients, who often forgot to all the attention of caregivers using the alert devices provided when then needed to get out of their beds. Secondly, it is proposed that the facility institutes structured, purposeful hourly rounds involving interdisciplinary care teams to help identify the patients in need of assistance and ensure that the falls prevention and reporting safeguards, such as call lights, recognition bands, bed and chair alarms, and support crutches are in place and functioning as required. The quality as gap analysis had revealed that many patients did not use the alert devices whenever they needed to leave their beds or they did not have these devices in place while in bed. Thirdly, a training program targeting all nurses and supplementary personnel involved in patient care at the unit is recommended to ensure that the fall prevention protocol is well understood and adhered to through comprehensive compliance. This proposal was informed by the low adherence to safety protocols by the caregivers because they did not comprehend the importance of risk appraisal and its beneficial influence on reducing in-hospital fall incidences. Many caregivers were unfamiliar with the details in the Patient-Centered Fall Prevention Toolkit, the Fall TIPS (Tailoring Interventions for Patient Safety) established by the Joint Commission, which prescribed safety practices that would reduce fall incidences and enhance patient safety. Thirdly, a multiprofessional team training program is proposed and is expected to emphasize the importance of accurate, complete and precise reporting data and documentation by the nurses to avoid wrongful decisions, and the importance of immediate feedback about these reports to those that produced them. The training also inculcates the desired practice attitudes and diligence towards the monitoring of patients and prevention of falls. The training proposal should have a teach-back component that would facilitate reskilling and upskilling of the caregivers, and an evaluation of the learning process to establish that effective learning had occurred to significantly influence the proposed practice change. This proposal is inspired by the high occurrence of incomplete, inaccurate and imprecise data alongside the lack of immediate feedback of the reports generated by the reporters. Fourthly, a debriefing process following every fall incident at the facility is proposed. The debriefing is expected to involve all care staff attending to patients at the trauma facility and would review the fall incident comprehensively to identity the lapses in practice and devise interventions to prevent reoccurrence. The debriefing component is informed by the observation that the caregivers had not learned from the previous mistakes that had caused the high patient fall incidences and the absence of collaborating learning in which caregivers learn from each other’s experiences during fall incidences (Jones et al., 2019). Finally, a cultural change is proposed to help instill a safety culture at the trauma facility. The quality and safety gap analysis had revealed that the existing culture at the trauma facility did not promote patient safety sufficiently to lower fall incidences. Incongruence in the perceptions of the top management at the facility and that of the caregivers was identified as the cause of the lack of a cohesive and coherent safety culture at the trauma facility (Lamb et al., 2020). This proposal is instigated by the persistent lapses in practice that have persisted and continued to cause an increase in patient fall incidents despite concerted efforts by the management and administration to improve safety performance at the facility. The cultural change would have an educational component that emphasized the importance of supporting patients whenever they needed to move out of their beds, ensuring that safety monitoring and alert equipment were in place and functional, the need to have frequent rounds to attend to the needs of patients and collect data on patient behavior, and promoting a collaborative learning culture in which successful care practices were shared among the multidisciplinary team members to establish a common knowledge and practice base and standard.

Support for Implementation and Adoption of the Proposed Practice Changes

The proposed practice change was devised systematically to facilitate a structured change implementation that prioritizes certain components of the proposal. The hospital’s top leadership and administration are expected to support the practice change initiative fully by facilitating and supporting the proposed programs, considering that the facility has a strained nurse-to-patient ratio. The support includes modifying the electronic medical records (EMR) to facilitate documentation and information sharing across the care team members and their leaders. Similarly, the leadership team could champion the change implementation by communicating effectively with the multidisciplinary care team to ensure buy-in and reduce resistance. Such communication would unearth the concerns of the healthcare practitioners that would hinder the implementation process and performance thereafter. In addition, the nurse leadership would support the implementation and adoption of the proposed practice changes by involving the nurses in formulating the implantation plan and process. This would also increase the nurses’ cooperation and reduce resistance. Consequently, such collaboration would help the trauma to achieve the benchmarked patient fall frequency of 3.4 falls per 1000 patient days. Nurse leaders can play a critical role of monitoring the implementation and effectiveness of the proposed practice changes. The nurse leaders can spearhead the monitoring of quality and safety performance metrics, such as significant and enduring reduction in fall incidences, elimination of extended hospital stays, and reduction in facility expenditures. It is expected that the close monitoring of these metrics would help evaluate the success of the implementation of the practice change proposals and the inculcation of a quality and safety culture at the rural teaching community Level II trauma center.

References

Duckworth, M., Adelman, J., Belategui, K., & Feliciano, Z., Jackson, E., Khasnabish, S., Lehman, I. S., Lindros, M. E., Mortimer, H., Ryan, K., Scanlan, M., Spivack, L. B., Yu, S. P., Bates, D. & Dykes, P. (2019). Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: An implementation science study. Journal of Medical Internet Research, 21(1), e10008. https://doi.org/10.2196/10008

Jones, K. J., Crowe, J., Allen, J. A., Skinner, A. M., High, R., Kennel, V., & Reiter-Palmon, R. (2019). The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: A quasi-experimental evaluation of a patient safety demonstration project. BMC Health Services Research, 19(1), 1-14. https://doi.org/10.1186/s12913-019-4453-y

Lamb, K. V., Ambutas, S.A., Sermersheim, E. R., & Ellsworth, M. J. (2020). Gap analysis: A tool for staff engagement in fall reduction improvement processes. Nursing Management, 51(10), 16-22. https://doi.org/10.1097/01.numa.0000698108.86942.f9

Patient Safety Network. (2019, September 7). Falls. https://psnet.ahrq.gov/primer/falls