Introduction
The Community General Hospital faced a severe increase in inpatient fall cases in the past six months. The falls occur primarily in the Medical-Surgical second-floor unit between 7 and 10 p.m. Patient fall-related incidents create a significant problem from the IOM’s framework of six aims of improvement standpoint. Most importantly, the increasing number of falls undermines the aim of safety — avoiding harm to patients from the care intended to help them (Agency for Healthcare Research and Quality [AHRQ], 2018). In addition, the growing number of fall cases illustrates the negligence of the patient-centered approach since the medical staff fails to demonstrate responsiveness to patients’ needs. Consequently, the number of reported falls steadily grows, negatively affecting the reputation of the Community General Hospital.
Given the worrying facts, developing and implementing a quality improvement (QI) initiative for a fall prevention program is necessary. A designated group of hospital staff members should assemble as a special team and assess the situation via the specific methods and tools of healthcare services quality improvement. It is crucial for the Community General Hospital to solve the problem of patient falls before it inevitably lead to patient harm.
Quality Improvement Methods and Tools
Quality improvement must be perceived as a dynamic rather than a static process. In general, the instruments used in QI it can be divided into two levels — methods and tools. The methods can be understood as overarching frameworks, whereas the tools are used for solving specific issues. Regarding the patient fall problem, one can apply two popular methods — the PDSA (plan-do-study-act) Cycle and the Lean Six Sigma. Flowcharts and brainstorming can be used as effective tools within the popular QI methods.
In the following sections, I will provide the theoretical explanation of the PDSA Cycle, Lean Six Sigma, Flowchart, and Brainstorming methods and tools. I will illustrate their successful use in practical examples from modern healthcare settings. In addition, I will explain how these methods and tools may be used to solve the problem of patient falls in the Community General Hospital.
Methods
The PDSA Cycle QI method based on an experimental approach and feedback has confirmed its effectiveness in clinical settings. For instance, Fridman (2019) used it to promote change from reactive to proactive care delivery to prevent patient falls during toileting procedures. The quality improvement team consisting of frontline nursing and leadership representatives championed innovative purposeful rounding behaviors instead of reactive hourly rounding. In the end, the fall rates per 1000 patient days decreased from 3,28 in Q3 of 2013 to 1,73 in Q1 of 2016 (Fridman, 2019). The key to success was careful planning based on pilot study data, dutiful implementation, and thorough feedback evaluation.
The Lean Sigma Six method used to develop the cost-effective DTAP for patients with femur fractures has also led to success. The waiting time before the operation was reduced from 6,57 to 2,91 days on average (Scala et al., 2020). The QI team skillfully applied the DMAIC (define-measure-analyze-improve-control framework to highlight the areas of change during the pre-operative, surgical, and post-operative phases. The positive outcome was particularly noticeable among the vulnerable patients aged over 65 — the percentage of them undergoing femur fracture surgery within 48 hours had increased from 9% to 64% (Scala et al., 2020). Overall, these two cases illustrate the effectiveness of the PDSA Cycle and Lean Six Sigma QI methods, as well as their applicability to the problem in the Community General Hospital.
PDSA Cycle Implementation
The case of the Community General Hospital provides certain valuable and reliable data. In particular, it is known where and when the patient falls have begun occurring more frequently. Given this knowledge, the QI team can undertake the following steps for addressing the issue within the PDSA Cycle framework. During the planning stage, the team will identify the most probable risk factors behind the evening-time falls in the Medical-Surgical unit and solicit the opinions of the patients and nursing staff. For example, the recent surge of fall-related incidents may stem from the slippery floor and steps, insufficient lighting, inadequate awareness of the nursing team, or all of these reasons. Afterward, a plan developed according to the feedback from the nurses and patients will be implemented over a sufficiently long period. The preliminary outcomes will be constantly studied to create a dynamic picture of the plan’s effectiveness. Finally, the solution will either be revised or accepted and followed by monitoring activities. Overall, the QI team will create a single loop feedback circle that would allow dynamic learning and make the eventual decrease in fall-related incidents possible.
PDSA Cycle Image
It illustrates the problem and the continuous single-loop feedback circle dedicated to searching for a solution. “P” represents the planning stage, “D”— doing, “S” — studying, and “A” — acting, respectively. The problem is stated in the middle circle. The cycle has no clear end, demonstrating the continuity necessary for tracing the impact of changes.
Lean Six Sigma Implementation
Unlike the PDSA Cycle method, the Lean Six Sigma approach is linear in implementation. In the case of Community General Hospital, the DMAIC framework will be implemented in five consecutive stages. Firstly, a problem will be identified; additional information will be solicited from the patients and nursing staff. Secondly, the sample of patients will be divided into sub-classes depending on age, gender, and complications in health conditions. The division of the sample will make possible a more precise identification of the main factors behind the patient fall incidents. Once the factors are identified, the hospital’s QI team will develop a set of appropriate corrective measures. Lastly, the effectiveness of proposed interventions will be tested over a sufficiently long period to validate the results. Overall, the Lean Sigma Six method may also be used for developing a reliable solution to fall-related incidents.
Lean Six Sigma Method Implementation Schedule
The Lean Six Sigma method implementation in QI can be presented as a Gantt chart. The team will start parallel work on stages from D to me, respectively, to save time. For instance, measurements of risk factors in various patient groups can be performed simultaneously with an analysis of already available information. Once the corrective interventions are developed and implemented, a year-long testing period would make checking their effectiveness possible.
Tools
A QI team can use multiple tools that facilitate the corrective interventions’ development and implementation. For instance, flowcharts can provide healthcare workers with guidance on how to act in various situations related to possible fall incidents. Therefore, flowcharts serve as a convenient tool for introducing a comprehensive fall prevention strategy (Coughlin et al., 2019). In particular, flowcharts are useful for understanding which patients might be more susceptible to fall-related incidents.
Furthermore, it is important to realize that team efforts such as fall prevention program development might benefit contribution from every member. Therefore, constructive feedback from the nursing team is particularly valuable for learning and tracking the effectiveness of implemented corrective measures. Team meetings that include brainstorming, discussions, and reflective sessions are one of the most popular tools of experiential learning (Shaw, Kiegaldie, & Farlie, 2020). In this regard, brainstorming sessions where every group member is encouraged to share their experience can be considered good practice for the QI team.
Fall Prevention Flowchart
One can see an approximate example of one of the standard flowcharts related to the fall prevention program at Community General Hospital. After the patient admission stage (1), the nursing team must conduct a fall risk assessment of every patient (2). In particular, such factors as a history of falls and abnormalities in balance and gait must be recorded. If these risk factors are identified, a patient should be informed (4) about the fall prevention program (FPP). However, if the risk factors are not evident, the nursing team should remain alert and document any patient falls (5). Finally, the nurses must provide feedback on fall-related incidents during the regular QI team meetings (6). Overall, the flowchart tool serves as a relatively simple and helpful manual for nursing team members who might become confused by the changes in standard procedures.
Conclusion
Brainstorming can serve as a valuable source of additional information about the factors behind the surge of fall-related incidents in the Community General Hospital. This assessment tool allows QI team leadership to quickly solicit frontline nurses’ opinions and pinpoint potential sources of the problem. Consequently, these sources can be targeted with appropriate corrective measures. In addition, prompt feedback from the nursing team is extremely valuable for evaluating the effectiveness of the new interventions. Finally, brainstorming activities may help bolster team spirit and engagement in work since input from every team member will not only be appreciated but actively sought. Therefore, such tools as brainstorming and reflective sessions are recommended regardless of the preferred QI method.
References
Agency for Healthcare Research and Quality. (2018). Six domains of health care quality.
Aidemark, J., & Askenäs, L. (2019). ‘Fall prevention as personal learning and changing behaviors: Systems and technologies’, Procedia Computer Science, 164, pp. 498-507. doi: 10.1186/s12877-020-01819-x
Coughlin, D., et al. (2019). ‘Falls prevention process in assisted living communities’, Journal of Applied Gerontology, 38(6), pp. 805-824. doi: 10.1177/0733464817748776
Fridman, V. (2019). ‘Redesigning a fall prevention program in acute care: building on evidence’, Clinics in Geriatric Medicine, 35(2), pp. 265-271. doi: 10.1016/j.cger.2019.01.006
Scala, A., et al. (2020). ‘Lean Six Sigma approach to implement a femur fracture care pathway at “San Giovanni Di Dio e Ruggi d’Aragona’ university hospital’, In European Medical and Biological Engineering Conference, pp. 740-749. doi: 10.1007/978-3-030-64610-3_83
Shaw, L., Kiegaldie, D., & Farlie, M. K. (2020). ‘Education interventions for health professionals on falls prevention in health care settings: a 10-year scoping review’, BMC Geriatrics, 20(1), pp. 1-13. doi: 10.1186/s12877-020-01819-x