HHA FALL PREVENTION 16
Quality/Safety Improvement Need Assessment and Plan Paper: Home Healthcare Fall Prevention
Ferris State University
Corinne Bradley
Abstract
Elderly falls are a concern in healthcare today related to the occurrence, cost, and injuries that occur. Falls can lead to decreased ability to care for one’s self related to physical and psychological harm. The cost of falls in the elderly affects the patient, family, and the healthcare system. Home Healthcare Agencies have the ability to reduce falls through fall prevention programs and collaboration with acute care facilities, physicians, and community resources. High reliability standards, just culture, and quality improvement models are critical to creating sustainable process change in all healthcare settings. It is the ethical responsibility of leaders in healthcare to ensure patient safety through quality care.
Quality/Safety Improvement Need Assessment and Plan Paper: Home Healthcare Fall Prevention
Falls are an area of serious concern in the elderly population. The Centers for Disease Control (CDC) report that falls are the leading cause of death related to injury, as well as trauma related hospital admissions in the United States (Boddice & Kogan, 2009). Brownhill (2013) reports that falls make up the top three out of five reasons for admission in Emergency Departments (ED). Approximately 1.64 million people age 65 or older are treated in EDs annually with about 78% being discharged to their homes (Russell et al., 2010). This increases the risk for subsequent falls if appropriate resources are not in place.
Home Healthcare Agencies (HHA) have the ability to assist in decreasing falls in the elderly population through collaboration, assessment, intervention, and prevention activities. By working with hospitals and other community resources the HHA can impact the number of falls as well as readmissions to acute care facilities related to reoccurrence of falls (Boddice & Kogan, 2009). 75-80 percent of those enrolled with HHAs are elderly, creating a strategic position for HHA to decrease fall occurrence through prevention measures (Boddice & Kogan, 2009). The purpose of this paper is to support the need for Fall Prevention Programs in HHA while evaluating healthcare needs throughout the continuum, including high reliability standards, just culture, and quality improvement. A plan will be proposed as to how to initiate a fall prevention program meeting the Nurse Sensitive Indicator related to patient falls, as well as consideration of ethical concerns.
Needs Assessment
A vast majority of falls occur in the community setting with approximately one third of those 65 years and older falling annually; of this population ten percent sustain serious injuries (Kelsey, Procter-Gray, Hannan, & Li, 2012). When senior citizens are frail the percentage of falls increases to fifty percent annually (Markle-Reid et al., 2010). At the age of 80 years and older the percentage of falls without consideration of frailty is fifty percent (Lee, Mills, & Neily 2012). When elderly patients are hospitalized there is greater emphasis on safety then in the community/home setting (Berland, Gunderson, & Bentsen, 2011). A root cause analysis study conducted by Lee et al. (2012) found that most falls occur in the patient’s home. Berland et al. (2011) expand on this concern with statistics that demonstrate the increased risk of death with two or more subsequent falls.
Falls not only increase mortality and physical injury to clients but can create psychological concerns for both the patient and the family. Patients who experience falls can suffer from fear and anxiety of falling again, loss of confidence in conducting activities of daily living (ADL), and may develop limitations functionally (Stenhagen, Ekstrom, Nordell, & Elmstahl, 2014). With this fear/anxiety and decreased level of functioning, a decrease in quality of life can occur. Stenhagen et al. (2014) noted a substantial decrease in quality of life of those who had a history of falls. With all of these considerations patients are at risk of an overall deficiency in remaining self-sufficient (Lee et al., 2012). When patients become less self-sufficient it requires a great deal of care from the family which can in return cause challenging dynamics and consideration of placement of a loved one into a care facility. The cost associated with placement in care facilities impacts the family as well as the healthcare system.
The cost of falls in the elderly is extreme and usually predictable and preventable. In 2000 the cost of falls in the United States equaled out to 19 billion with an estimated cost increase to 43.8 billion in 2020 (Lee et al., 2012). These costs are directly related to medical care and not the cost to the family or patient in relation to functional status and caregiver strain. Not only is cost considerations of great importance, but also the mortality associated with falls in the elderly. According to Lee et al., (2012) only half of those admitted for a fall will survive for a full year. This has called attention to accrediting bodies as well as government agencies to ensure best care is provided to the elderly population.
With recent healthcare initiatives it is imperative to look toward the benefits of HHA in reducing hospitalizations and readmissions. “Extensive reform initiatives have given rise to fewer acute care hospitals and increasing pressure to continue to expand and enhance home care services for older, more vulnerable, and frail individuals within the confines of economic constraint” (Markle-Reid et al., 2012, p. 140). Centers for Medicaid and Medicare Services (CMS) have been looking toward establishing patient falls as a measure of process for HHA (Fortinsky, Baker, Gottschalk, King, Trella, & Tinetti, 2008).
HHAs have the ability to assist in the prevention of falls in the community through multiple care initiatives. When primary care physicians notice a health decline in a patient, home health services can be ordered to assist in the rehabilitation and support of the patient and family. If a patient is discharged from the hospital and a concern of falls is present, HHA can provide the necessary surveillance to ensure safety in the home. There are constraints to this occurring, including a lack of communication and collaboration between various healthcare entities. Data suggests that preventable adverse events such as falls are directly related to deficiencies in healthcare systems, especially inadequate communication between care providers (Markle-Reid et al., 2010).
Another constraint involves inadequate education and participation of fall prevention initiatives by patients. Patients who receive home healthcare services are more likely to be admitted to hospitals due to falls, directly related to the lack of participation in fall prevention activities (Smith & Lewin, 2008). Lack of standardized policies and procedures, assessment tools, and training are directly linked to the inadequate fall prevention initiatives of HHAs currently (Lee et al., 2012). It is critical that adequate evidence-based assessment tools are utilized with all patients to assess fall risk potential. It is also imperative that staff is educated on the importance of fall prevention initiatives and fall risk assessment. By developing standardized policies and process across the healthcare system, training, tools, and expectations can be established with staff, primary providers, hospitals, and the community.
Evaluation
In order to create effective healthcare initiatives and change, many considerations must be taken into account. High reliability standards ensure that patient safety is in the forefront of decision making and new process development. Just culture supports these safety initiatives by encouraging adverse event reporting, while ensuring a non-punitive evaluation that still holds employees accountable. Quality improvements models are used to ensure that structure and evidence-based research is utilized to ensure best practices are in place. The following few sections will discuss these concepts in greater detail, as well as the pertinence to a fall prevention program development.
High Reliability Standards
High reliability standards are an important initiative in healthcare today. The Joint Commission (TJC) has stressed the importance of organizations implementing these standards and becoming a High Reliability Organization (HRO). There are four main areas of consideration with high reliability standards including leadership, a culture of safety, robust process improvement (RPI), and the continual drive to remain current in research and best practices (Chassin & Loeb, 2013). Leadership is critical in any change process as they not only approve the change, but must support the change through leading by example. Leadership involves everyone from the board of directors, to the chief executive officer, to physician, to quality management staff, to quality measures, and information technology. Without full collaboration of all entities safety measures may not be successful.
A culture of safety is another necessity in meeting high reliability standards. A culture of safety entails trust, accountability, identifying conditions that are unsafe, system strengthening, and assessment (Chassin & Loeb, 2013). Trust must be established in order for employees to feel safe reporting adverse events or events that could have become adverse. Accountability is necessary for all employees from human resources, to environmental services, to front line staff with hands on care of patients. Constant evaluation of possible unsafe conditions should be part of day to day operations of every healthcare entity. To be able to fully strengthen a system adverse events need to be analyzed using root cause analysis to ensure safe guards are established to prevent future occurrence (Chassin & Loeb, 2013). Assessment needs to occur not only with actual processes and services but also utilizing failure mode evaluation analysis to anticipate possible complications and ensure safe guards are in place. A culture of safety requires a collaboration of all employees in the organization by creating a just culture.
Just Culture Principles
Just cultures are necessary to ensure safe quality care is provided to patients across the healthcare continuum. Just culture involves evaluating the role of the system in adverse events while still holding staff accountable for behavior that is considered at risk or reckless (Marx, 2007). Most adverse events in healthcare are directly related to system failures; however human behavior must be evaluated as well. Marx (2007) discusses human behavior in three categories, human error, at-risk behavior, and reckless behavior. Human error is inevitable especially when safe guards are not established to assist in the prevention of adverse events. At-risk behavior requires attention from leadership to fully understand the nature of the behavior and assist the employee in improving care practices. Reckless behavior involves a “choice to consciously disregard a substantial and unjustifiable risk” (Marx, 2007, slide 15). With all of these situations it is critical for nursing leadership to be aware of staff behavior and establish a culture of proactive learning, accountability, and setting expectations (Marx, 2007). Miranda and Olexa (2013) further this distinction through the 2012 initiatives established by the Agency for Quality Healthcare and Research (AHRQ); "just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior (p, 6). Just cultures allow for evaluation of adverse events, and discussion of process improvement plans to ensure safe, quality care is provided.
Quality Improvement Models
In light of recent healthcare changes quality care has become imperative to reimbursement as well as accreditation. A model of care can be defined as a guide in how care should be provided to ensure best outcomes (Sherwood & Barnsteiner, 2012). The quality improvement model that will be discussed is from TJC (2013) in regards to national patient safety goals. The national patient safety goal (NPSG) of focus is in correlation with home health care and patient falls. NPSG.09.2.01 relates to reducing the risk of falls in the home health patient (TJC, 2013). The elements of performance that guide quality improvement involve assessing the patient for fall risk, implementation of interventions to decrease falls based on risk assessment, education of staff on fall prevention initiatives, education of the patient and family on fall prevention strategies, and evaluation of the effectiveness of the fall prevention activities (TJC, 2013). All of the elements of performance are critical to the prevention of falls and improving the outcomes of the patient at risk for falls. The next section will provide an example of the evaluation concepts in regards to fall prevention in HHAs.
Evaluation Concept Application
Fall prevention in HHA requires high reliability standards, a just culture, and a quality improvement model. By following the elements of performance established by TJC (2013), the HHA has clear guidelines to the expectations of the accrediting body. Not only must system deficits be analyzed, but staff accountability to set standards must be in place. Home healthcare can be a challenging environment due to the autonomy of the professional staff in the field. It is critical that staff fully understand policies/procedures and expectations. This is even more critical when it comes to patient safety. A just culture in regards to fall prevention initiatives ensures that not only does the system have a strong policy and procedure in place, but that staff are fully trained in the policy and procedure with expectations being set. When the policy and/or procedure are not followed and a fall occurs a root cause analysis needs to be performed to determine if changes should be made to the process or if reckless behavior was involved. If it is deemed that reckless behavior was involved a zero tolerance as explained by the AHRQ must be followed without exception. This requires high reliability standards to be utilized to ensure that leadership is involved in not only the development of the process, but also in the follow through, evaluation, and continual change that the process will need to meet the needs of the every changing healthcare system. Examples of the implication of these principles will be further discussed in the following section introducing a brief overview of the proposed plan.
Proposed Plan
The proposed fall prevention plan for the HHA is directly related to the nursing sensitive indicator, patient falls (American Nurses Association, 2014). The plan consists of a comprehensive assessment, prevention, and evaluation plan for all patients admitted to the HHA. Before the actual prevention program can begin, an interdisciplinary team will be established to develop a concise standardized policy and procedure to be followed. Lee et al. (2012) through a root cause analysis demonstrated the importance of policy standardization in fall prevention programs. In fact standardization was one of the major root causes in patient falls due to lack of cohesive directions for staff in regards to process and expectations, which is directly correlated to the creation of a just culture as discussed above. Areas of consideration by the interdisciplinary team will include the utilization of evidence based research to fully understand fall risk factors, best practice fall assessments, effective fall prevention initiatives, and evaluation methods to ensure effectiveness of the program. High reliability standards will be met through the interdisciplinary collaboration and utilization of evidence-based research, such as a study conducted by Tzeng and Yin (2008) who provide insight into TJC recommendations including illumination, non-slip footwear, chair, bed, and toilet seat height, bed alarms, and frequent caregiver rounding to ensure safety. The team will also utilize TJC (2013) NPSG elements of performance as a guide to the development of the program, ensuring that a quality improvement model is utilized.