Introduction and Problem Statement
Clinical Practice Problem
The findings from the latest organizational assessment and evaluation indicate several discrepancies in the performance of the organization. One of the pertinent issues is the lack of improvement in the occurrence of patient falls in the rehabilitation setting. Admittedly, the assessment did not reveal an increase in the number of falls, which would be a much more substantial cause for alarm. However, the problem of the occurrence of falls among the patients is associated with a multitude of the adverse health effects and contains a potential risk of negative patient outcomes observable in the long run.
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Therefore, it is necessary to address the issue by identifying the ways of reducing the current rate of falls among patients in the rehabilitation setting and ensure the longevity of the improvement by incorporating the change in the organizational culture.
It should be emphasized that the development and facilitation of the project should be performed in accordance with the principles of evidence-based practice. In this way, the outcomes of the project can be estimated based on the results of similar projects available in the academic literature and adjusted to the specificities of the practice setting at hand. In addition, evidence-based practice is necessary to ensure the effectiveness of the selected solution and may provide insights regarding the possible challenges to implementation.
Performance Improvement Project
According to the latest value report issued by the organization, the incidence of falls is decreasing steadily. While the comprehensive data on the matter is unavailable, at least one issue that is known to contribute to the falls incidence (the use of high-risk medications in the elderly) shows a clearly decreasing trend, which is consistent with the report. However, the reported improvement constitutes an 18 percent decrease over five years, which can be interpreted as less than four percent per year (Carolinas HealthCare System, 2016).
Such rate of decrease is insufficient to be considered satisfying in terms of patient safety requirements. Another area of concern is the financial performance of the organization, namely its recent reported increase in operating income by 58% (Haefner, 2017). Since the occurrence of falls constitutes in a noticeable financial burden, it is reasonable to consider the project as necessary for the optimization of the organizational performance.
Alignment with Mission and Strategic Plan
The organization’s mission clearly states that the improvement of health is one of its foremost priorities. In its current form, the project clearly aligns with the stated goal due to the fact that the issue of patient falls has numerous direct detrimental effects on the physical health of the patients. On many occasions, the injuries obtained as a result of the fall not only require additional care but also aggravate the recovery process related to the patient’s initial condition.
Next, the mission emphasizes advanced healing for all, which can only be achieved as a result of the uninterrupted rehabilitation process and is evidently disrupted by the introduction of the risk factor of the fall. Finally, the mission mentions elevation of hope as a part of the threefold goal, which can be indirectly attributed to the perceived quality of care received by patients, satisfaction rate, and, by extension, to the overall quality of life.
Since the project is expected to increase the long-term outcomes in each of the identified areas, it can be said that it is consistent with the organization’s mission. The same can be said about the vision of Carolinas Healthcare System, which states the intention to become the first and best choice of care. Since both patient preference and the quality of care are directly dependent on the patient outcomes, it would be reasonable to expect the improvement in all of the related areas as a result of successful project implementation.
The strategic plan conceived by the organization focuses on several areas of organizational activity, including patient safety, clinical efficiency, patient outcomes, and an overall quality of service. Constant improvement is specified as the main approach to reaching the identified objectives and creating a better experience for the patients. At the same time, the improvements in patient safety and patient outcomes are direct goals of the project at hand, which indicates its compatibility with the organization’s strategic plan.
The population impacted by the identified problem is comprised of the entirety of the patients admitted to the rehabilitation unit of the Carolinas Healthcare System. Due to the admission specificities, the proportion of the elderly individuals is higher within the population. It should be noted that the older individuals exhibit the higher likelihood of falling in the clinical setting due to numerous factors. Specifically, a number of health conditions that are more prevalent among the older population, such as osteoporosis, arthritis, arthrosis, and rheumatism are also known to increase the occurrence of falls (Healey & Darowski, 2012).
Next, the mental state of the identified population’s segment is often characterized by dizziness, headaches, fatigue, insomnia, and common mental disorder, all of which contribute to the clinical problem at hand (Karlsson, Magnusson, von Schewelov, & Rosengren, 2013).
Next, the rehabilitation capacity of the organism of the older adults is noticeably lower than that of the rest of the population due to the effects of aging. This fact further aggravates the adverse health effects of the fall by extending the time required for the recovery and increasing the complexity of respective additional care. In other words, a significant segment of the population in question displays the characteristics that make it both more likely to be impacted by the problem and more vulnerable to its negative effects.
Context and Climate
According to the findings of the organizational assessment, the organizations possess a strong culture of innovation and a robust tradition of industry leadership with a rich historical record dating back more than seventy years. The orientation towards safer clinical practice combined with the possibility to deliver and share the vision is expected to assist the process of addressing the identified problem.
Finally, the innovation engine embedded in the macrosystem’s organizational culture is expected to further inhibit the problem after the project’s onset due to the buildup of the innovation skills among the employees and the capacity for disruptive innovation and a deliberate stance towards the intention to learn from the leaders in the industry.
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Interdisciplinary Communication and Collaboration
It is also worth mentioning that the advantage of being affiliated with the macrosystem in question includes the possibility of the individual organizations to participate in the knowledge sharing program. This program allows the participants to share their practices and resources while at the same time retaining their autonomy. Considering the widespread character of the issue, it is reasonable to expect the availability of relevant experience among the organizations, which can be characterized as strength.
Evidence to Support the Project
The existing academic literature contains substantial data to support the project. According to the current consensus, the occurrence of falls in hospital setting leads to numerous adverse health effects and significantly increases the time and resources due to additional care administered to the patients (Cumbler, Simpson, Rosenthal, & Likosky, 2013). The problem is especially relevant among older patients who, due to the combination of age-related risk factors, are especially vulnerable to falls.
The data suggests that the majority of negative health outcomes associated with falls can be traced to the delirium, dementia, impaired mobility, and the side effects caused by multiple medications, all of which are more prevalent in elderly patients (Cumbler et al., 2013). According to Aizen and Zlotver (2013), the risk factors identified in the literature can be successfully utilized to predict the occurrence of falls.
The study suggests that dementia can be a significant predictor of falls whereas delirium exhibits a limited degree of significance in terms of predictive validity. In addition, several risk factors, such as the admission after an arthroplasty and the usage of a wheelchair were shown to be a negative predicting factor (Aizen & Zlotver, 2013). It is worth mentioning that while the study was not directly aimed at the issue of falls in a specific setting, four out of five locations used to gather data were rehabilitation units. In other words, the findings have a high degree of applicability to the specific setting of the project.
Another important aspect of the problem is that the identified population segment is known to exhibit slower recovery rate from the injuries attained during a fall and, as a result, receive the greatest impact from the phenomenon. In addition to the numerous adverse health impacts and a disrupted recovery process, the long-term outcomes of the issue include the decrease in the health-related quality of life (HRQoL) and life satisfaction (LS).
A study by Stenhagen, Ekström, Nordell, and Elmståhl (2014) provided evidence that the occurrence of falls among the patients is positively associated with a substantial decrease in both the RLQoL and LS both at baseline and after six years. The latter finding is especially significant since it outlines the indirect long-term effect of falls on the population and contains major implications in the domain of public health. Importantly, the overall long-term impact of patient falls as suggested by the results of the study is both greater and more persistent than previously estimated (Stenhagen et al., 2014). Therefore, it would be reasonable to seek ways to reduce the rate of falls in order to increase patient satisfaction and minimize the need for extended care in the future.
Next, it is important to understand the financial aspect of the problem. In addition to the numerous detrimental health effects, the occurrence of falls poses a serious economic challenge to the health care organizations.
According to the recent estimates, the average cost of fall-related injuries among the patients experiencing a fall in a clinical setting amounted to more than $9,000 per Medicare beneficiary, with a significant proportion of the expenditures allocated to skilled nursing facility, inpatient care, and outpatient care, respectively (CDC, 2016). The group with a higher likelihood of falls was exposed to a higher risk of persistently high expenses to mitigate the adverse health effects. The total estimated cost of care provided to the patients impacted by falls exceeded $13 billion (CDC, 2016).
The overwhelming majority of the expenses occur for the non-fatal injuries. Finally, the results suggest that the cost is substantially greater for female patients, likely due to the increased severity of injuries and the complexity of the recovery process (CDC, 2016). To sum up, the phenomenon has a noticeable impact on the economic aspect of the functioning of healthcare providers and the reduction of falls can alleviate financial pressure, allowing for a more efficient allocation of resources.
Finally, the extended care required for the patients following the occurrence of the fall creates additional challenges for the staff in the organizational setting. The most apparent related effect is the increased workload for the nursing staff associated with care necessitated by the injuries obtained as a result of the fall. Such outcome is especially undesirable considering the persistent shortage of staff in the healthcare facilities as it is expected to lead to the inadequate human resource distribution in an attempt to address prolonged rehabilitation period.
By extension, it is possible to expect excessive workplace stress and, eventually, a decline in performance of the nurses within the facility (Dall’Ora, Ball, Recio-Saucedo, & Griffiths, 2016). Admittedly, the direct relationship between the said factors is scarcely explored in the academic literature. However, it is possible to imply the connection based on the established relationship between the occurrence of falls and the need for extended care as well as the negative impact of the increased workload and the decline of performance in nurses (Miake-Lye, Hempel, Ganz, & Shekelle, 2013).
Clinical Practice Guidelines
As was explained in the previous section, the occurrence of falls as well as its detrimental effect on patient health has been thoroughly studied. One of the important points to consider is the fact that the issue is largely preventable, which means that in many cases a fall can be avoided and, by extension, the average rate within the unit or across the facility can be successfully decreased. To attain the consistency of the process and systematize the existing knowledge, the clinical practice guidelines have been formulated by the major healthcare organizations. While the guidelines can contain minor differences at some level, their core principles are recurring throughout the setting.
Commonly, these guidelines include three principal components. First, a set of universal fall precautions is suggested, including the well-defined protocols. The list of precautions commonly includes installation of the technical precautionary measures and alarms, familiarization of patients with the environment and the available measures, organization of the environment in the most optimal way (e.g. placement of the personal belongings within the immediate reach of the patient), installation of handrails in the locations of the increased risk, providing the patient with the adequate and safe footwear, and maintaining uncluttered environment.
Despite the evident benefits of the precautionary measures and the perceived lack of major barriers to their facilitation, the adherence to them may be unsystematic and, as a result, produces little to no improvement of the problem (Karlsson et al., 2013). In addition, it is important to understand that the effective implementation of the measures requires consistent integration in the hospital culture and needs to be accompanied by training of the clinical and nursing personnel of the organization in order to produce consistent results.
The second aspect of the guidelines is the use of a standardized assessment of the risk factors allowing the prediction of falls. Scalable solutions are available for the assessment process, which means that it can be implemented at the individual level as well as applied to the selected unit or the entire organization. Similarly to the universal precautions discussed above, in order to be effective, this assessment must be administered systematically in order to achieve the necessary level of consistency in the reduction of falls (Karlsson et al., 2013).
The most feasible approach for ensuring consistency is the integration of the procedure into the hospital routines so that every patient would be subject to the same set of questions. In this way, the individual risks unique to each admission would be accounted for in the final version of the patient’s care plan. It should also be stressed that some of the factors influencing the likelihood of falls can change over time and become irrelevant by the next admission or even during the course of admission. For this reason, the guidelines usually emphasize the need for a seamless update of the assessment results to ensure their relevance.
The third aspect of the guidelines is the integration of the findings of the assessment into the care planning process. The implementation process involves the creation of an action plan that acknowledges the findings of the assessment and includes the strategies and techniques allowing for the reduction of the likelihood of falls.
Such care plan is a synthesis of numerous interventions and tactics available in the literature and adjusted according to the specificities of the practice setting and the experience of the practitioner. Importantly, the patient education plan should include the possibility to educate the patients and their families in order to ensure the longevity of the effect and maintain the positive outcome in the long run.
Similarities and Differences
The themes pertinent to the issue exhibit a range of similarities with the related topics. Most prominently, the long-term effects of the problem are comparable to those of the majority of the issues associated with the prolonged stay in the hospital. In addition, the issue of readmission exhibits a similar range of issues including economic, organizational, and resource challenges. Both areas put additional pressure on the hospital staff, introduce increased expenses, and have several direct and indirect influences on the patients’ quality of life and level of satisfaction in the long run. The main difference from the identified areas lies in the fact that the issue is largely preventable through organizational means and adjustments in practice, which does not require a significant allocation of resources directly.
Findings and Gaps
The findings of the available literature on patient falls address numerous negative effects associated with the issue and provide exhaustive evidence of their significance. It also contains multiple recommendations on reducing the occurrence of the problem and supplies evidence in favor of each of them. The literature notably lacks the evaluation of indirect long-term effects of the issue. However, it is possible to assume that these effects are similar to those produced by the intermediary causes such as increased workload and prolonged hospitalizations, and can be acknowledged accordingly.
The reviewed academic literature on the topic of patient falls contains exhaustive evidence of the adverse health effects associated with the problem and provides multiple approaches intended to decrease its occurrence in hospital settings. The research demonstrates a notable gap in the understanding of the long-term effects of the issue. While these effects can be implied from the related research, it is necessary to conduct studies in order to locate the specific factors and determine their relative weight.
Action Plan for Change
Aim, Objectives and Outcomes
The proposed change is based on the introduction of several universal fall precautions in order to reduce the rate of falls in the rehabilitation setting. The most basic precautions include the familiarization of the patients with the environment to minimize confusion and improve their orientation at all times, installation of alarms and communication means (e.g. call lights) within the reach of the patients, organization of the environment in a way that minimizes the risk of falling (e.g. placement of the most frequently used items within the patient’s reach), and providing the patients with comfortable footwear that prevents slipping, among others.
Most importantly, the proposed change involves the introduction of the scheduled rounding protocols that would be performed for each patient on an hourly basis in order to assess the individual risk of falls and implement the respective precautions. The protocols suggested for implementation contain the evaluation of the patient’s pain levels, toileting assistance, evaluation of the state of bed breaks and wheelchairs if available, inquiry on the comfort of the current bed position, administering the scheduled medications, assessment of the item placement, and a generalized offer of assistance.
The described precautions will be applied to all patients in order to ensure consistency and achieve improvement throughout the setting. The ultimate goal of the project is to decrease the rate of falls among patients. The goal will be reached through several intermediary objectives, such as the optimization of the environment and the increase of patients’ familiarity with the means of communication and fall prevention equipment. A separate set of objectives (e.g. the alignment of the values upheld by the personnel with the goal of change) will reflect the integration of the change in the organizational culture.
Finally, a separate objective will address the quality of training of the staff aimed at the integration of the precautions. The outcomes expected to occur as a result of successful implementation include the decreased rate of falls and, by extension, the improved patient outcomes, greater patient safety, improved efficiency of care, increased health-related quality of life, and patient satisfaction rate. It is also reasonable to expect the improvement in the financial domain, with the decreased expenses associated with extended care and an optimized workload distribution among the personnel.
Evidence in Support of the Project
The effectiveness of the suggested change in the form of the introduction of the universal fall precautions and the establishment of the rounding protocols has been confirmed by numerous studies. For instance, a study by Spanaki et al. (2012) explored the effects of implementation of strict safety protocols in the epilepsy monitoring unit. According to the results of the study, the safety efforts which included scheduled rounding protocols, resulted in the statistically significant 15% reduction of falls within the unit alongside other improvements, such as the reduction in missed seizures (Spanaki et al., 2012).
An integrative literature review by Hicks (2015) summarizes the findings from several sources exploring the effects of implementing the practice in different settings. The review focuses on the studies with large samples. The author concluded that the introduction of rounding led to the reduction in falls per 1000 patient days (Hicks, 2015). A similar conclusion was reached in the article by Spoelstra, Given, and Given (2012).
The studies used in the review were selected based on the criteria of the quality of evidence. The researchers identified several components associated with the most significant improvement. The majority of the components, such as the installation of alarms, modification of environment, education and training of the staff, and scheduled risk assessment, are consistent with the elements of the universal fall precautions suggested as a part of the project (Spoelstra et al., 2012). Importantly, the components in question were combined into multifactoral prevention programs, which apparently increased their efficiency.
The value of multifactoral intervention is further corroborated by the findings of a meta-analysis by Vlaeyen et al. (2015). The study in question explored the relative effectiveness of the single-component, multiple-component, and multifactoral intervention. Importantly, the meta-analysis did not reveal a statistically significant effect of the interventions on falls. However, the rate of recurrent falls was reduced, with multifactoral interventions being associated with greater improvement than single-component ones (Vlaeyen et al., 2015). Considering the information from the available academic literature, it would be reasonable to conclude that the current evidence supports the feasibility of the chosen means of improvement.
Several elements of the environmental culture are expected to support the implementation of the project. The most apparent component is the innovation engine that operates at the macro-level within the organization. The lean start-up model used as a part of the engine’s methodology can be used as a boosting factor for the project at the initial stage of implementation provided that the economic and organizational benefits can be laid out and the reasons for assistance can be substantiated.
In addition, the design thinking sessions can result in more productive solutions and enhance the problem-solving capacity of the involved staff. Finally, the existence of the catalyst program can become useful for a seamless introduction of innovative solutions and create a favorable environment for the development and utilization of effective methodologies.
Another important part of the organizational culture that is expected to serve as a catalyst is the presence of a robust knowledge sharing program. With its help, it will be possible to gain access to relevant experience of the affiliated organizations where safety precautions were successfully implemented in the past. In addition, the existence of the reliable communication channels introduces additional safeguard in the form of the timely response to the unforeseen barriers. For instance, it is likely that some of the organizational challenges will be similar within the rehabilitation setting across the macrosystem, which enables the stakeholders to overcome such inhibition by consulting with the units that have already implemented similar adjustments.
Applicable Change Theory
Due to the fact that the proposed change is a relatively common occurrence in the healthcare setting, it is recommended to use Lewin’s three-step change model as a primary change theory. The theory suggests the existence of multiple forces inhibiting and stimulating change at any given time, resulting in equilibrium. It is thus necessary to disrupt the equilibrium in order to initiate the movement in the desired direction.
This can be achieved by increasing the driving forces favorable to change while at the same time decreasing the components that inhibit it. Once the movement is initiated, it is then necessary to sustain change in the desired direction by a combination of employee motivation, shared vision, and engagement. Finally, once the desired effect is achieved, it is necessary to re-freeze the change to make sure that its effects are sustainable and persistent. The re-freezing is often achieved by institutionalizing the change and introducing the monitoring mechanisms.
In accordance with the identified model, the initial phase of the project will require the organization of the sessions where the staff will be briefed on the importance of the fall prevention strategies, along with the description of the negative effects of the high fall rates and the improvements that are expected to occur after the successful change implementation. Simultaneously, training sessions will be initiated that would equip the employees with sufficient understanding of the principles of universal precautions and outline the basic tactics of their use in the workplace.
After this, the measures will be introduced into the setting. Importantly, the phase will also necessitate logging of the activities in order to track the success of implementation and measure the effectiveness of the outcomes more accurately. The progression will be tracked by setting the intermediary objectives and examining the ability of the team to meet them. Both the positive and negative results would be examined at the scheduled staff meetings in order to introduce adjustments to the protocols and the administration process if necessary. It would also be necessary to responsibly report improvement (if any) in order to boost employee motivation.
Once the desired result is reached, the next step would be to institutionalize the introduced measures. This will be done by codifying the exact steps performed during a rounding protocol and identifying the elements that require documenting and logging. It would also be reasonable to modify the HR practices to ensure sufficient understanding among newly recruited employees (e.g. through crash courses) and maintaining the necessary level of quality (e.g. through training sessions).
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