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Sustaining Improvements With Falls

Adults with Medical Staff at Home Young Female Doctor
Monday, August 6, 2018

At Inter-Community Hospital in Covina, California, patients are continually assessed for identifiable fall risk factors during admission and placed on appropriate intervention strategies. A review of the latest evidence-based practice in fall prevention did not identify any missing components of industry accepted techniques in fall prevention. Nevertheless, a new approach was needed. With the support of executive leadership, certified black belts, nurse leaders, a physician, and risk management specialists, a more formalized problem-solving approach using Lean Six Sigma was applied to the fall prevention issue.

Statistically significant root causes were addressed as follows:

  1. Inconsistent Placement of Best Practice Tools—A fall prevention kit was created that includes all fall prevention tools to ensure consistent application.
  2. Inconsistent Rounding—Hourly rounding by the bedside nurse, charge nurse, and certified nursing assistant is now standard work.
  3. Limited Visibility of High-Risk Patients—There are an insufficient number of rooms near the nursing station to accommodate all high-risk fall patients. To address this, mobile workstations are strategically placed in designated spots around the nursing unit to ensure quick response by staff members to call lights and bed alarms.
  4. Patient Knowledge Gap—Upon admission, patients and their families are given education about the heightened risk for falls as inpatients. The role they each play in safety and fall prevention is reinforced.
  5. Inadequate Measurement System—A standard fall debriefing form is used to gather specific information about any patient fall and is then applied to ongoing monitoring and analytics.
  6. Culture and Problem Visibility—A “fall board” is highly visible in each nursing unit. The number of days since the last fall is recorded daily by the charge nurse during staff member huddles. Rewards and recognition are given to nursing units at 30-day intervals for lowering fall incident levels.

In the beginning, frontline staff members believed that preventing falls in the hospital was an unattainable goal. As part of the change management strategy, staff members were involved during all stages of the project. This access and feedback proved especially vital at identifying root causes and targeted solutions.

As a result, nursing units have gone as long as 185 days without any inpatient falls, and the fall rate has steadily improved by 85 percent from 2015 to 2018. The culture has changed where staff members now believe falls can be prevented with a supportive process in place. The same methods have been spread to other hospitals in the system and have reduced falls in the system overall by more than 50 percent.

For more information, please contact Nena La Scala, CSSBB, Director, Lean Six Sigma Development, Inter-Community Hospital, at; or Denise Ronquillo, CSSBB, Corporate Director, Process Excellence, Inter-Community Hospital, at