Fall Prevention Quality Improvement Project

Running head: INDIVIDUAL ANALYSIS PAPER 1
Introduction
Falls are the main health challenge among old age people, especially in nursing homes. One
out of three older people fell at least once in a year which potentially causes the elevated risk of
fractures, chronic pain, depression and transfer to hospitals (Ambrose, Cruz, & Paul, 2015). A
large body of evidence suggests that appropriate interventions implemented in research settings
can reduce falls and fall-related injuries among older people living in nursing homes (Ganz, et al
2015). Unintentional falls cause the 90% hip fractures and 60 % head injuries in old age people.
Falls affect the daily activities of residents, raises health care costs and it is an increased burden
to the health care providers (Bowling, 2014). This paper will present the quality improvement
project to reduce the falls in my organization, analysis of the improvement project, principles of
the model, and the involvement of health care professionals in the model. In addition, this will
also discuss my own role and what further recommendations are provided for a quality
improvement project. The effectiveness of the project will be presented along with the
conclusion.
Description of the issue
Fall prevention in old age people is the major goal for healthcare professionals especially
working in the nursing homes. Residents living in nursing homes have more risk of falls due to
old age, medical diagnosis, treatment side effects and cognitive and/or motor deficits (Miller,
2018). Falls also lead to pain, fear, loss of independence, poor quality of life and can ultimately
contribute to death (Cooper, 2017). The implementation of fall prevention interventions in
nursing homes play a vital role to reduce the expenses of fall-related injuries and promote the
quality of life among elderly people. My current organization is facing frequent fall incidents

FALL PREVENTION QUALITY IMPROVEMENT PROJECT 2
among residents which potentially affect the physical and psychological well-being of residents.
The mission of my organization is to provide quality care to its residents, interprofessional
collaboration, staff education and reducing the expenses due to falling-related injuries. The
Restorative care committee decided to initiate the quality improvement project to decrease the
number of falls among residents. The healthcare professionals worked together in a team and
followed the fall prevention strategies in their daily practices to achieve the same goal of fall
reduction and promote the well-being of residents (Duan & Zou 2017). The quality
improvement initiative was based on the fall prevention education and post-fall huddles to find
the root cause of falls. The purpose of this initiative was to minimize the falls from the current
number that is 75% to 50% within six months from October 01/2018 to March 31/2019
Quality Improvement Model
The Plan Do Study Act (PDSA) model for quality Improvement was used for the purpose to
reduce the falls in nursing home residents. The Plan Do Study Act (PDSA) cycles supported staff
involvement in approving, assessment and reflecting on the modifications was made to
accomplish the aim of reducing or minimizing the number of falls by 25%. The fall improvement
group involved health care team that included, the restorative care staff, assistant director of care
(ADOC), physiotherapist, occupational therapist, Physician, RNs and RPNs and personal support
workers. The Standards for completion of the fall risk assessment tool on new admissions, post
falls and upon a change in resident status was approved by the improvement group in the care
home (Cooper, 2017).
The implementation of the well-known interventions demonstrates the do within the PDSA
model. Speakers from outside organizations especially from RNAO were invited for further

FALL PREVENTION QUALITY IMPROVEMENT PROJECT 3
education in the form of in services and education sessions about the use of fall risks assessment
tool and the importance of a multifactorial approach to minimize the number of falls. PDSA
decision and measure were made to educate the staff for fall risk assessments, Post fall huddles
to find the root cause, provide safe environment review fall risk medications with physician and
pharmacist. An individualized plan of care containing multi-factorial interventions for fall
prevention was initiated upon new admissions, post fall and during a change in resident's status
in the facility. The interdisciplinary team found that taking a positive team approach to
improvement and using the resource reduced their residents' falls and injuries due to falls
(Epstein, 2014). The resource included a multifactorial falls risk assessment, falling star logos
placed on assistive devices and bedsides of high fall risk residents and post-fall huddles to find
the root cause & action plan (Cooper, 2017).
In the study (Evaluate) and act (revise), part of the PDSA cycle the fall risk assessment
tool is repeated biweekly on fall risk residents regardless no changes in status are observed.
Improvement team frequently evaluated for the interventions initiated for the fall reduction
purposes, follow up with documentation and revise the care plans. It was found that most of the
falls occurred between 0400 to 0800 hrs due to toileting need. Interventions initiated and care
plans updated for toileting schedules. According to records, no serious falls were noted in the
facility within two weeks after the start of this model. In the scheduled time period the team
continued to collaborate for interventions, review the changes and measure the results. The team
accomplishes the goal to reduce the fall by 25% in the six months.
Analysis of the quality improvement model

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A process is strictly highlighted in the fall prevention quality improvement model. The Plan-
Do-Study-Act (PDSA) cycle - is a tool which tests a change by developing a plan, carrying out
the test, observing and learning from the consequences of the tested change and determining
what modifications should be made to the test (Christoff, 2018)
The strengths of the quality improvement model are fall prevention education to staff,
patients and families for fall prevention interventions and post-fall huddles with the
interdisciplinary team to find the root cause. A specific cause of fall can be identified during
post-fall huddles with an interdisciplinary team because falls could happen due to multiple
factors like mobility, medications or change in status (Duan & Zou 2017).
Good teamwork and collaboration played a very important role in the success of this project.
Each member had a strong understanding of their role in the team and they created their
individualized fall prevention care plans according to their own perspectives. The success of this
project leads to a reduction of time spent on documentation. This was helpful to save the
residents from potentially serious injuries happening due to falls and maintaining their self-
independence (Cooper,2017).
Despite the success, some limitations were experienced. Shortage of staff was the biggest
limitation. Evidence-based fall reduction interventions were not properly implemented by health
care providers due to the shortage of staff and a heavy workload. Full time scheduled staff who
had the same assignments of residents was more aware of the fall risk factors. More falls occur
when sometimes full-time scheduled staff pulled to other places from their regular working units
or in a case when casual or part-time staff replace the full-time staff in their absence. Secondly,
improvement group found it very hard to meet the prediction measure because some senior staff
was resistant to completing the tools as they believed that falls were part of the aging process and