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Proposal Format – Important! You only complete Part A during this course
Part A: PLAN (NURS 711)
A. Clearly explain the quality improvement project – what exactly are you planning to do?
To decrease the number of falls in the home by educating discharge planners on community resources as well as providing patient education materials. The targeted population will be those at risk for falls during their hospital stay being discharged with home health services; however all patients at risk for falls will receive community resources as well as educational material. The education material will be created by Corinne Bradley, the lead of this project. The educational material will consist of ways to safe proof homes, community resources, exercise programs, and medication review using Beers criteria (American Geriatrics Society, 2014).
B. Provide evidence based support that establishes a need for this project. Also include research support for effectiveness of the proposed improvement project.
The need for a project surrounding fall prevention in the community beginning during hospitalization stems from the high incidence of falls tracked through home health services. Bronson Lifespan had a fall occurrence of 91 reported falls in the first quarter of 2014. These falls are only those that are reported and only falls that involve one home health care company. The incidence of falls throughout the community is much greater and education on community resources, safe homes, and medication management are critical to decrease fall rates and the harm it causes to everyone involved.
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.
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 than in the community/home setting (Berland, Gunderson, & Bentsen, 2011). A root cause analysis study conducted by Lee, Mills, and Neily (2012) found that most falls occur in the patient’s home. Berland, Gunderson, and Bentsen (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. The Joint Commission (TJC) has issued a National Patient Safety Goal directly related to reducing harm caused by falls, requiring healthcare systems to address patient falls as well as develop programs to reduce the incidence of falls (Volz & Swaim, 2013). Furthermore Magnet Recognition Programs require that Magnet Accredited facilities monitor nurse sensitive indicators such as patient falls (Volz & Swaim, 2013). Beginning in 2008 Centers for Medicare and Medicaid Services (CMS) added patient falls to its list of hospital acquired complications that providers are not reimbursed for (Butcher, 2013).
Fall prevention programs utilizing a multidisciplinary approach have been supported to reduce the risk of falls in the home as well as the incidence of falls (Markle-Reid et al., 2013). Spiva et al. (2014) researched the effect of team training on the reduction of falls and found a reduction of 67% of all falls and a 71% reduction of injury. Nurses are a pivotal profession in healthcare and through their expertise and training can create great change. Kirkpatrick, Boblin, Ireland, and Robertson (2014) discuss the importance of nursing professionals in fall prevention and found that nurses truly impact change processes. Won-Jin, Moonyoung, and Duk-Hyun(2014) demonstrated a reduction in falls with the utilization of a community exercise program. The exercise program not only decreased the incidence of falls, but also increased independence in daily life activities of those participating. Leeet al. (2012) demonstrated through a root cause analysis that the main reason behind falls in the home is the lack of a fall prevention plan for those at risk. This project will target those at risk for falls in the hospital setting and through education provided to the discharge planning staff in team training sessions, community resources (including exercise programs) and patient education can be provided and a home plan will be established decreasing the risk and incidence of falls for the target population and healthcare system.
C. Where will this project take place? Describe the environment/facility/unit etc.
The project will take place at one of the acute care hospitals in the Bronson Health Care System, Bronson Battle Creek. The proposed plan will be implemented on three medical surgical floors with the number of patients ranging from 75-95. Calhoun County where Bronson Battle Creek is located is made up of a very diverse population including many Burmese decedents, factory workers, and elderly. The majority of population on the three targeted units is 60 years old and above.
D. Who else will be involved in this project? What will their roles be? (Include the agency and preceptor in this section, and provide an overview of the agency and the preceptor’s qualifications, title, and contact information. A signed agreement from the agency representative and preceptor should be included in this section.)
The project will be conducted at Bronson Battle Creek. The preceptor for this project is Heather West MSN, RN, Manager of Quality and Safety at Bronson Battle Creek. Heather has been working in quality and safety for the past few years and was recently promoted to the Manager from a specialist position. Heather has chaired many committees including the MISTAAR Committee and provided training to all employees on different topics including High Reliability Organizations. Michelle Link System Director of Case Management/Discharge Planning and Jill Beison MSN, RN Manager of Case Management/Discharge Planning will be involved to assist in setting up meetings with discharge planners to disseminate the information.
Heather West MSN, RN
Manager of Quality and Safety: Bronson Battle Creek
Bronson Battle Creek Hospital
300 North Ave.
Battle Creek, MI 49017
(269) 245- 8683
E. Complete an assessment of the QSEN graduate level competencies. Consider a minimum of 3 KSAs within the 6 competencies that you will focus on as a part of the overall quality improvement project. (Note: These should align with your project goals.)
Competency / Knowledge/Skill/Attitudes / Project AlignmentPatient Centered Care / Knowledge: “Analyze multiple dimensions of patient centered care: Information, communication, and education” (QSEN, 2014, Table 1). / For the success of this project information must be collected including community resources and programs. The information must then be communicated to the discharge planners/case managers to educate targeted patient populations (those at risk for falls while in the hospital).
Teamwork and Collaboration / Attitudes: “Value the influence of system solutions in achieving team functioning” (QSEN, 2014, Table 2). / Case Managers/Discharge Planners differ across the system. Michelle Link and Jill Beisonwill be crucial in ensuring a location based collaboration to ensure that appropriate education and resources are utilized to decrease readmissions to the hospital. This effort is a system solution to financial concerns, but requires collaborative functioning.
Evidence Based Practice / Skills: “Employ efficient and effective search strategies to answer focused clinical questions” (QSEN, 2014, Table 3). / In order to provide pertinent accurate information multiple community resources will need to not only be identified, but researched/interviewed to fully understand the resource and effectively answer clinical questions of case managers/discharge planners.
Safety / Knowledge: “Analyze potential and actual impact of national patient safety resources, initiatives and regulations” (QSEN, 2014, Table 5). / The Joint Commission has established a national patient safety goal around falls in healthcare. The target system has home healthcare, rehabilitation, and acute care so preventing home falls entails multiple aspects. CMS as noted previously has also included patient falls as a hospital acquired complication effecting reimbursement and the financial stability of the system.
F. Complete an assessment of the ANA Scope & Standards of Practice for your specialty role. Identify a minimum of three professional standards that will be met by completion of this project. (Note: These should align with your project goals.)
ANA Scope and Standard of Practice / Project ImplementationStandard 4 Planning: “The nurse administrator develops a plan that prescribes strategies and alternatives to attain expect outcomes” (ANA, 2009, p. 28).
Measurement Criteria: “Considers economic impact of the plan” (ANA, 2009, p. 28). / With appropriate fall prevention care planning for those at risk for falls in the hospital, the system will reap benefits related to advanced awareness of the importance of fall prevention (even while inpatient) of those at risk. CMS has stringent reimbursement rules related to falls for all entities of healthcare. By reducing the risk/incidence of falls in the home the return on investment for the training necessary will be beneficial.
Standard 5 Implementation: “The nurse administrator implements the identified plan” (ANA, 2009, p. 29).
Measurement Criteria: “Facilitates utilization of systems and community resources to implement the plan” (ANA, 2009, p. 29). / In order to provide necessary resources to patients at risk for falls both system and community resources will need to be evaluated and utilized. The education provided to case managers/discharge planners will include not only community resources but also system home health agency programs to assist the patient in reducing the risk of falling in the home and thus the actual incidence of falls.
Standard 10 Collegiality: “The nurse administrator interacts with and contributes to the professional development of peers and colleagues” (ANA, 2009, p. 38).
Measurement Criteria: “Shares knowledge and skills with peers and colleagues as evidenced by such activities as care conferences or presentations at formal or informal meetings” (ANA, 2009, p. 38). / The dissemination of information for the project will occur through a formal presentation with case managers/discharge planners. There will also be an initial proposal presentation to leaders of the system including Heather West (preceptor) and Michelle Link (System Director of discharge planning/case management), and Jill Beison (System Manager of discharge planning/case management). Care conferences will be utilized by the discharge/case managers to recognize patients at risk for falls during hospitalization.
Standard 13 Research: “The nurse administrator integrates research findings into practice” (ANA, 2009, p. 41).
Measurement Criteria: “Assures research priorities align with the organization’s strategic plans and objectives and include an appropriate nursing focus” (ANA, 2009, p. 41). / Bronson Health Care System has dedication to four dimensions known as the “4 C’s: Clinical Distinction, Corporate Vitality, Exceptional Customer Service, and Community Health Catalyst” (Bronson, 2014). The strategic plan is to move toward an even more value based system. Value based systems focus on patient outcomes and patient satisfaction (Bronson, 2014). This project will support all of the “4 C’s” as it will improve clinical distinction by reducing fall risk/incidents, improve corporate vitality related to decreasing readmissions, improve customer service by involving patients in discharge planning, and finally by improving community health by improving participation in community health programs and reducing falls in the community.
G. Complete an RCA or FMEA with key stakeholders and/or peers with an understanding of the issue you will be addressing. Include a conceptual map as part of your plan. (Note: Examples you may use are included in this project guide.)
The attached RCA and FMEA were conducted to analyze the causes of falls in the home and potential barriers/failure modes for the proposed project. When conducting the RCA many aspects were considered including psychological, environmental, pharmaceutical, physical, and psychosocial concerns. The 5 why methodology was used to fully understand how the listed factors could contribute to patient falls.
When considering the psychological aspects that could contribute to a patient falling in their home many why questions were asked. There is the potential for misuse or not using walking devices, but why would a patient not utilize the assistance when present? It could be due to lack of knowledge on how to operate the assistive device, pride, or the device may be in disrepair. Also psychological concerns of fear of falling, bad balance, and cognition were discussed. All of these aspects lead to a lack of adequate education and support to assist the patient in remaining safe in their home.
Environmental concerns consist of inadequate lighting, use of appropriate non-slip footwear, tripping hazards, and outdoor walkways. Why are these concerns? If patients have loose rugs, their feet or walking devices could get caught increasing the risk of falls. If the patient has on socks without grips they could slip on wood or tile flooring very easily. If lighting in the home is not adequate the patient may not see an obstacle and may trip. Outdoor walkways must be kept clear of ice, snow, wet leaves, and any other tripping hazard such as a hose. Again adequate education to families and patients is necessary to ensure that these items are addressed in the home setting, making the transition home safer and the risk of falls less.
Medication management is a large concern in the elderly population overall and its potential impact of patient safety/falls is imperative. Many older adults take many medications and may not fully understand all of the side effects. When side effects are not monitored, the patient may choose to perform an activity that would best be performed after the window for occurrence of side effects. There is also the concern of taking medication as prescribed and again with lack of knowledge/confusion/poly-pharmacy this can be very challenging in the elderly population. High risk medications are another concern related to patient safety. The Beers criteria will be utilized to ensure that patients are aware of the potential safety concerns of their medications prior to discharge.
Another safety concern in the elderly related to falls is physical in nature. Urinary frequency/urgency is one of the largest concerns as elderly are fearful of having an accident and may rush to the bathroom, putting them at risk for falling. Bowel habits present the same concern, especially when laxatives or stool softeners are being used. Another physical concern is that of hypotension. Many elderly take antihypertensive medication, and need to monitor how they feel when changing orthostatic positions. Anticoagulation therapy poses a risk for the severity of injury if a fall occurs, related to the thinning of the blood and potential for life threatening hematomas.