D156 Patient Fall Reduction Improvement Project Analysis and Implementation

D156 Patient Fall Reduction Improvement Project Analysis and Implementation

Student Name

Western Governors University

D156 Business Case Analysis for Healthcare Improvement

Prof. Name:

Date

Healthcare Improvement Project: Introduction and Project Initiation

Organizational Problem

What is the healthcare improvement project about?

The healthcare improvement project aims to develop an appropriate, focused screening tool to identify patients at high risk of falls in a hospital-based outpatient department (HOPD). Additionally, it involves conducting a compliance audit to ensure adherence to fall prevention interventions. Preventing patient falls is a key priority aligned with the National Patient Safety Goal (NPSG) set by The Joint Commission (Joint Commission, 2024).

Why is this improvement project necessary?

Currently, the screening documentation tool is inadequate because it fails to accurately identify patients with a high risk of falling. This deficiency prevents nurses from implementing tailored fall prevention strategies, thereby compromising patient safety. Additionally, the absence of auditing capabilities in the HOPD makes it difficult to monitor compliance and the effectiveness of fall prevention interventions consistently. Introducing a screening tool will enable nurses to identify high-risk patients accurately, apply the appropriate safety interventions, and enhance overall patient safety. Meanwhile, the auditing tool will monitor compliance with CMS standards, providing monthly feedback to the interdisciplinary team on documentation accuracy and intervention adherence. This feedback will facilitate continuous quality improvement by informing necessary adjustments in the fall prevention process.

What is the current process for fall precautions in the HOPD?

Currently, all patients in the outpatient department are placed under universal fall precautions. This means that every patient receives basic fall prevention measures, such as non-skid shoes, having the call light within reach, and nursing assessments of mobility independence, regardless of their individual diagnosis or procedure. Documentation involves a simple checkmark in the electronic medical record (EMR) indicating that these precautions were applied at patient check-in. This one-size-fits-all approach limits personalized care and has contributed to increased patient falls.

What problems arise from the current system?

Because interventions are not personalized, patients at higher risk are not receiving targeted fall prevention measures. Also, the inability to audit compliance in the outpatient setting hinders leadership from identifying areas needing improvement. This lack of targeted screening and monitoring results in increased fall incidents and reduced safety for vulnerable patients.

Stakeholders

Who are the key stakeholders involved, and what are their interests and influences?

Each stakeholder plays a critical role in the success of the project through their unique expertise and authority. Their collaboration ensures that fall prevention strategies are evidence-based, well-communicated, and consistently implemented.

Project Team

What are the roles and responsibilities of the Project Manager?

The project manager serves primarily as a planner and a control monitor. As a planner, the project manager oversees the project timeline and ensures milestone goals are met. Effective communication and coaching are essential components of this role to keep the team aligned and motivated. As a control monitor, the project manager tracks team performance and compliance with the fall prevention interventions, using data analysis to assess progress and determine if adjustments are necessary.

What skills are crucial for the project manager?

Two key skills for the nurse leader serving as project manager include interpersonal communication and executive functioning. Strong interpersonal communication fosters team motivation and collaboration, and the ability to listen empathetically to staff concerns is vital during times of change. Executive functioning involves problem-solving and adaptability, enabling the leader to analyze challenges, make informed decisions, and adjust strategies as needed for project success.

What are the Clinical Nurse Specialist’s roles and responsibilities?

The CNS functions as both a collaborator and an expert in research. Collaboration involves working with the project team, other CNSs, and quality and safety coordinators to maintain consistent practices across facilities. The CNS’s research expertise ensures that interventions are evidence-based and align with CMS guidelines. Their responsibilities include investigating best practices for fall prevention and verifying that clinical practices comply with regulatory standards, which is essential to maximize the project’s effectiveness.

Needs Assessment

What assessment method was used to identify the root causes of the problem?

The project utilized the “Five Whys” technique during the Clinical Practice Evaluation (CPE) phase to explore underlying causes of increased patient falls and poor documentation in the HOPD Short Stay unit. This iterative questioning revealed gaps such as the need for a fall-risk screening tool and specific intervention recommendations.

How were themes identified through stakeholder discussions?

A meeting was held with stakeholders where presentations detailed fall statistics over two years, incident report summaries, and a Five Whys cause analysis. Discussions focused on reasons for patient falls, the impact of patients’ medical conditions on mobility, challenges in identifying fall-risk patients, and communication gaps among staff. The consensus was that inadequate screening documentation and failure to personalize interventions based on fall-risk status were primary contributors to patient falls.

What key findings did stakeholders identify?

Two important findings were that labeling all patients as fall risks resulted in failure to deliver appropriate interventions to truly high-risk patients, and that the lack of clear communication about patients’ mobility assistance needs among staff increased fall risk. Absence of clear fall-risk identifiers led to inconsistent care and higher incidence of falls.

SWOT Analysis

What are the strengths, weaknesses, opportunities, and threats related to the project?

How will weaknesses and threats be mitigated?

To address the challenge of rapid patient turnover, the plan includes collaboration with the informatics specialist to create an efficient, streamlined screening tool with auto-populated interventions to minimize staff burden. Clarification of documentation expectations will be sought through clinical nurse specialist and quality and safety leaders, with nurse educators providing comprehensive training to build staff confidence.

To overcome external threats, leadership has granted permission for the facility’s Short Stay Unit to pilot the screening and auditing project independently before a wider network rollout. This approach allows for troubleshooting and localized adaptation. The lack of CMS-specific regulations will be countered through collaboration with the CNS to identify best practices and pilot them, with the long-term goal of establishing tailored policies for outpatient care areas.

How will strengths and opportunities be maximized?

The project will leverage the expertise of unit-based educators and clinical nurse specialists to rapidly develop and deploy educational materials via the staff education portal. Their involvement ensures staff are well-prepared, and that remediation occurs when needed. Leadership support will facilitate quick decision-making and resource allocation to sustain the initiative.

Leveraging Organizational Strengths for Project Success

Senior leadership authorization provides a critical foundation for this Health Improvement Plan (HIP) by allowing the Short Stay Unit to function as an independent pilot site for the fall prevention screening and intervention tools. This autonomy increases the likelihood of project success and supports scalability across the broader network if outcomes are favorable. Early and ongoing endorsement from on-site senior leaders has already demonstrated measurable value by accelerating decision-making and reinforcing staff engagement.

Equally important is the involvement of quality and safety coordinators, whose expertise in regulatory standards and compliance strengthens the development of a defensible and effective documentation framework. Their contributions ensure that fall prevention interventions align with internal policies and external expectations while remaining practical for frontline nursing staff.

The availability of a designated unit-based educator further enhances implementation fidelity. This role supports just-in-time education, staff coaching, and audit-driven remediation when practice gaps are identified. Close collaboration with the educator allows the project to leverage existing educational materials and adult-learning strategies, thereby improving staff competency and adherence.

In addition, the presence of an on-site clinical nurse specialist (CNS) is a strategic asset. The CNS contributes advanced clinical insight, familiarity with local workflows, and expertise in evidence-based practice. Established professional relationships with CNS colleagues across the health system also facilitate cross-site benchmarking and the exchange of best practices, strengthening the overall design of the HIP.

Impact Analysis

The impact analysis yielded a benefit score of 10 and a risk score of 6, resulting in a benefit-to-risk ratio of 1.67. This finding demonstrates that the anticipated advantages of reducing patient falls substantially outweigh the associated risks. Identified risks included potential financial burden, variable nursing compliance, and challenges related to staff buy-in. However, these concerns were outweighed by projected benefits such as reduced fall-related costs, improved patient outcomes, enhanced staff morale, and stronger patient safety culture.

Collectively, the analysis confirms that implementation of the proposed fall prevention strategies is justified and aligned with organizational priorities for quality and safety improvement.

Justification and Project Purpose

The primary purpose of this HIP is to reduce patient falls in the hospital-based outpatient department (HOPD) Short Stay Unit through the development and implementation of a focused fall risk screening and individualized intervention process. Currently, the unit relies on universal fall precautions, which, while well intentioned, fail to account for individual patient risk factors. This lack of personalization has contributed to persistent fall events.

The project addresses this gap by collaborating with key stakeholders to design a targeted screening tool specific to the Short Stay patient population. In parallel, the HIP seeks to establish tailored interventions that correspond to identified risk levels, thereby improving patient safety and care quality.

HIP and Addressing the Problem

The Short Stay Unit faces an elevated fall risk due to the absence of a structured, population-specific screening process. High patient turnover, varied acuity levels, and limited length of stay further complicate fall prevention efforts. Universal precautions alone have proven insufficient to mitigate these risks. By implementing a focused screening tool and corresponding interventions, this project directly targets the underlying contributors to patient falls within the HOPD environment.

Summary of Findings

Needs Assessment Summary

A needs assessment using the 5 Whys methodology identified inadequate fall risk screening and inconsistent documentation as primary contributors to patient falls in the Short Stay Unit. A SWOT analysis highlighted strong clinical expertise and leadership support while identifying operational challenges such as time constraints, high patient throughput, and unclear documentation expectations.

An impact analysis further confirmed that the benefits of reducing patient falls and improving outcomes outweighed potential risks, supporting progression of the project.

SWOT Summary

The organization demonstrates significant internal strengths, including access to clinical nurse specialists and unit-based educators. However, internal weaknesses such as inconsistent documentation practices and limited staff time remain barriers. External opportunities, including leadership engagement and educational resources, provide momentum for change, while threats such as variable feedback from multiple sites and limited outpatient regulatory mandates require proactive management.

Impact Analysis Summary

An overall impact score of 1.67 indicates that the benefits of fall reduction initiatives exceed the risks. Cost savings, improved patient outcomes, and enhanced staff morale provide strong justification for implementation despite identified challenges.

Review of Relevant Scholarly Sources

Current evidence strongly supports multifactorial and multidisciplinary approaches to fall prevention. Research consistently demonstrates that interventions combining risk screening, mobility assessment, environmental modification, medication review, and staff education are more effective than isolated strategies.

Studies by Bustamante-Troncoso et al. (2020) and Hammouda et al. (2021) emphasize the effectiveness of multidimensional and multifactorial interventions in reducing fall incidence and associated complications. Jordahl et al. (2024) further demonstrate the impact of nurse-driven mobility programs, reporting a 22% reduction in falls through structured mobility assessment and interprofessional collaboration.

Global and national guideline analyses reinforce the importance of individualized care plans informed by validated screening tools (McKercher et al., 2024; Montero-Odasso et al., 2021). Additionally, McVey et al. (2024) highlight the critical role of clear and consistent communication in sustaining multifactorial fall prevention practices. Evidence from outpatient settings, including STEADI-based initiatives, supports the applicability of structured fall risk screening beyond inpatient units (Wallace & Vonnes, 2024).

Project Environment

The Joint Commission identifies fall risk screening as a core patient safety standard. Its guidance promotes systematic assessment of fall history, medication use, mobility limitations, and cognitive status upon admission and throughout the care episode. Adherence to these standards enables early identification of high-risk patients and supports the implementation of targeted interventions such as bed alarms, non-slip footwear, enhanced supervision, and environmental modifications.

Implementation of these guidelines aligns the HIP with national safety standards while supporting organizational goals related to quality outcomes, regulatory compliance, and patient satisfaction.

Stakeholder Perspective and SMART Goal Synthesis

Key stakeholders, including the clinical nurse manager, unit-based educator, quality and safety coordinator, unit director, and project manager, participated in structured discussions to review fall data from the previous two years. Analysis revealed an increase in falls during 2024 compared to 2023, underscoring the urgency for process improvement.

Stakeholders agreed that improving fall risk assessment and intervention processes would enhance patient outcomes, satisfaction, and organizational reimbursement. Regulatory considerations, particularly CMS reimbursement implications, further reinforced leadership support. Consensus was reached on a target reduction of 5% in patient falls by the end of the first quarter, with defined monitoring strategies and assigned roles.

Project Management Lifecycle

The Four Project Management Lifecycle Phases

The HIP follows a structured four-phase project management framework. The initiation phase defined the project scope, identified stakeholders, and assessed feasibility using needs assessment, SWOT, and impact analyses. The planning phase established timelines, resources, and responsibilities. During implementation, the screening tools and interventions will be deployed, monitored, and refined. The evaluation phase will assess outcomes and generate lessons learned to inform future quality improvement initiatives.

SMART Goal Framework

The SMART goal was developed collaboratively with stakeholders to ensure feasibility and alignment with organizational priorities.

SMART Project Goal

The project aims to achieve a 5% reduction in patient falls in the Short Stay Unit by April 29, 2025, through the implementation and auditing of newly developed mobility screening tools and high-fall-risk protocols. Progress will be measured using standardized fall quality indicators. The project will commence on December 5, 2024, following institutional approval, and conclude prior to the anticipated graduation date.

Process Key Performance Indicators

References

Bustamante-Troncoso, C., Herra-Lopéz, L., Sáncez, H., Pérez, J. C., Márquez-Doren, F., & Leiva, S. (2020). Effect of a multidimensional intervention for prevention of falls in older adults. Primary Care, 52(10), 722–730. https://doi.org/10.1016/j.aprim.2019.07.018

Burns, E., Kakara, R., & Moreland, B. (2022). A CDC compendium of effective fall interventions (4th ed.). Centers for Disease Control and Prevention.

Hammouda, N., Carpenter, C., Hung, W., Lesser, A., Nyamu, S., Liu, S., et al. (2021). Moving the needle on fall prevention: A GEAR network scoping review and consensus statement. Academic Emergency Medicine, 28, 1214–1227. https://doi.org/10.1111/acem.14279

Jordahl, D., Laitsch, M., Coto, J., Variava, F., Suda, E., & Justice, S. R. (2024). Evidence-based practice project to decrease falls through the implementation of a nurse-driven mobility program. MEDSURG Nursing, 33(5), 228–232. https://doi.org/10.62116/MSJ.2024.33.5.228

McKercher, J. P., Peiris, C. L., Hill, A. M., Peterson, S., Thwaites, C., Fowler-Davis, S., & Morris, M. E. (2024). Hospital falls clinical practice guidelines: A global analysis and systematic review. Age and Ageing, 53(7), afae149. https://doi.org/10.1093/ageing/afae149

McVey, L., Alvarado, N., Healey, F., Montague, J., Todd, C., Zaman, H., et al. (2024). Talking about falls: Communication of fall risk in hospitals. BMJ Quality & Safety, 33(3), 166–172. https://doi.org/10.1136/bmjqs-2023-016481

Montero-Odasso, M. M., et al. (2021). Evaluation of clinical practice guidelines on fall prevention. JAMA Network Open, 4(12), e2138911. https://doi.org/10.1001/jamanetworkopen.2021.38911

D156 Patient Fall Reduction Improvement Project Analysis and Implementation

The Joint Commission. (2023). Preventing falls and fall-related injuries in health care facilities. The Source, 21(1), 3–6.

Wallace, M., & Vonnes, C. (2024). Implementation of STEADI fall risk screening in ambulatory oncology. International Journal of Safe Patient Handling & Mobility, 14(3), 90–99.

Joint Commission. (2024). National Patient Safety Goals. Retrieved from https://www.jointcommission.org/standards/national-patient-safety-goals