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NURS FPX 6212 Assessment 2 Executive Summary

Student Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name:

Date

Executive Summary 

In-patient falls are the quality and safety issues encountered in _________ (mention the organization’s name used in A1). These fall incidences have resulted from insufficient fall prevention measures and poor healthcare practices. This executive summary discusses the quality and safety outcomes of in-patient falls and their value for the organization. Moreover, it elaborates on the role of leadership in implementing proposed changes. 

Quality and Safety Outcomes Measures

In-patient falls are significant adverse events within healthcare organizations that lead to severe patient complications and impose poor consequences on the healthcare organization (LeLaurin & Shorr, 2020). Several key outcome measures are crucial in assessing quality and safety outcomes related to in-patient falls within our organization. 

  • Fall Rates are quantifiable numbers that evaluate the frequency of falls per patient population and the number of hospital days over a specified period (AHRQ, n.d.). The strength of this outcome measure lies in its ability to allow the healthcare organization to track trends, identify high-risk patients, and evaluate the impact of interventions on reducing fall incidences. However, a weakness of this measure is its reliance on accurate reporting, as underreporting falls is a common concern in healthcare settings. 
  • Fall-related Injuries: Since fall-related injuries are expected consequences of in-patient falls, this outcome measure will help assess falls’ severity and impact on patient well-being (Kenis et al., 2022). This includes examining the types of injuries. However, a weakness of this measure is the variability in injury reporting and classification, which can affect the consistency and comparability of data across different departments. 
  • Cost: According to Dykes et al. (2023), in-patient falls result in additional costs for patients due to medical treatment, rehabilitation, extended hospital stays, and organizations due to increased healthcare utilization. Measuring costs associated with fall events evaluates the financial impact of falls on healthcare organizations. Assessing the cost of in-patient falls gives valuable insights into resource allocation and budget planning. However, a weakness of this measure is the challenge of accurately attributing costs solely to falls, as other factors may also contribute to healthcare expenditures within the organization.

Strategic Value of Outcome Measures 

The outcome measures maintain strategic value for the healthcare organization in improving the quality of care and establishing a safety culture. These outcome measures offer valuable insights into the effectiveness of fall prevention initiatives and the safety of the care environment within __________ (mention the organization’s name used in A1). For instance, monitoring fall rates and conducting a data comparison with benchmarks permits healthcare facilities to identify areas for improvement and effectively allocate resources to address those quality improvement areas (AHRQ, n.d.; Bhati et al., 2023).

Ultimately, it helps improve the quality of care by reducing adverse events and enhancing patient outcomes. Similarly, by assessing the types and severity of injuries resulting from falls, organizations can identify root causes and opportunities for intervention. The existing outcome measures, such as fall rates and fall-related injuries, can provide additional value to the organization by informing targeted interventions and resource allocation. 

NURS FPX 6212 Assessment 2 Executive Summary

Furthermore, measuring the cost associated with in-patient falls provides strategic insights into the financial impact of adverse events on patients and the organization (Dykes et al., 2023). This supports strategic goals related to financial sustainability, resource allocation, and operational efficiency. Consequently, by comparing these measures with factors like staffing levels and environmental conditions, organizations can uncover underlying trends to optimize fall prevention efforts, enhance patient safety, and improve overall quality of care. 

The Relationship Between In-patient Falls and Outcome Measures

In-patient falls represent a systemic problem within __________ (mention the organization’s name used in A1). This systemic problem has direct implications for quality and safety outcomes. Turner et al. (2022) mention that fall incidences result in various adverse outcomes such as injuries, prolonged hospital stays, increased healthcare costs, and psychological distress for patients and families. Thus, the specific quality and safety outcome measures are interconnected with the systemic problem. For instance, an increase in fall rates may correlate with higher rates of fall-related injuries, indicating a greater risk to patients. Moreover, fall-related injuries and healthcare costs highlight the importance of prevention efforts in improving an organization’s patient safety and quality of care. 

However, additional data can be gathered to advance understanding of in-patient falls within our organization, elucidate contributing factors, and inform targeted interventions. A potential information area concerns the environmental factors within healthcare facilities that lead to fall events. Stathopoulos et al. (2021) state that gathering data on environmental factors will help the organization eradicate environmental hazards that increase fall risk and guide and improve the safety of patients’ physical environment.

Additionally, data on staffing levels and workload among healthcare providers can provide insights into staffing-related factors that may impact patient supervision and fall prevention practices. This information will develop a comprehensive understanding of in-patient falls and assist in implementing targeted strategies to mitigate risk and improve quality and safety culture. 

Outcome Measures and Strategic Initiatives 

The strategic plan of __________ (mention the organization’s name used in A1) in the context of preventing inpatient falls focuses on improved healthcare practices through training and education, standardization of fall assessment and prevention efforts, and interdisciplinary collaboration. Our organization encourages healthcare providers to foster a quality and safety culture to prevent adverse events and improve patient experiences. According to Shaw et al. (2020), by monitoring these metrics, our organization can develop and implement targeted training programs to enhance staff competency in recognizing fall risk factors, implementing preventive measures, and responding effectively to fall events.

Moreover, these outcome measures provide benchmarks for sustaining the standardized protocols and interventions in reducing fall rates and associated financial burdens (AHRQ., n.d.)Additionally, data collection and reporting of these metrics enable healthcare teams from different disciplines to collaborate and develop comprehensive strategies for fall prevention, leveraging their diverse expertise to address clinical, environmental, and systemic factors contributing to fall risk.

Leadership Role 

The proposed practice changes for our organization include standardization of fall risk assessment protocols, staff training and education, and the development of multidisciplinary fall prevention teams. Leadership roles and commitment are substantial in implementing and adopting proposed practice changes. Their role is divided into three categories: provision of clear direction, availability of resources, and creating ownership and accountability. Leaders are responsible for communicating the importance of fall prevention efforts, emphasizing their alignment with organizational goals and patient safety priorities (Gifford et al., 2019). They must establish clear communication channels through instant messaging or staff portals to minimize misunderstandings, foster collaboration, and promote trust among team members.

Secondly, leaders must allocate and arrange adequate resources for training programs, protocol development, and team formation, ensuring that adequate support is available for implementing and sustaining the proposed changes. Lastly, a blame-free culture must be established for accountability among team members and healthcare providers. Establishing performance metrics and monitoring regular progress will hold individuals and teams accountable for adherence to new practices and achievement of desired outcomes. By demonstrating commitment, leaders can support the successful implementation and adoption of practice changes to drive quality improvements and create a safety culture (Els et al., 2024).

References 

 AHRQ. (n.d.). How do you measure fall rates and fall prevention practices? https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus15(10), e47731. https://doi.org/10.7759/cureus.47731 

Dykes, P. C., Curtin-Bowen, M., Lipsitz, S., Franz, C., Adelman, J., Adkison, L., Bogaisky, M., Carroll, D., Carter, E., Herlihy, L., Lindros, M. E., Ryan, V., Scanlan, M., Walsh, M.-A., Wien, M., & Bates, D. W. (2023). Cost of in-patient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. JAMA Health Forum4(1), e225125. https://doi.org/10.1001/jamahealthforum.2022.5125 

Els, R. C., & Meyer, H. W. (2024). The influence of leaders’ attitudes and commitment to quality management of training on organisational excellence: A mixed-methods study. Human Resource Development International, 1–31. https://doi.org/10.1080/13678868.2024.2315925 

Gifford, W., Lewis, K. B., Eldh, A. C., Fiset, V., Abdul-Fatah, T., Aberg, A. C., Thavorn, K., Graham, I. D., & Wallin, L. (2019). Feasibility and usefulness of a leadership intervention to implement evidence-based falls prevention practices in residential care in Canada. Pilot and Feasibility Studies5(1), 103. https://doi.org/10.1186/s40814-019-0485-7 

NURS FPX 6212 Assessment 2 Executive Summary

Kenis, C., Decoster, L., Flamaing, J., Debruyne, P. R., De Groof, I., Focan, C., Cornélis, F., Verschaeve, V., Bachmann, C., Bron, D., Van den Bulck, H., Schrijvers, D., Langenaeken, C., Specenier, P., Jerusalem, G., Praet, J.-P., De Cock, J., Lobelle, J.-P., Wildiers, H., & Milisen, K. (2022). Incidence of falls and fall-related injuries and their predictive factors in frail older persons with cancer: A multicenter study. BMC Geriatrics22, 877. https://doi.org/10.1186/s12877-022-03574-7 

LeLaurin, J. H., & Shorr, R. I. (2020). Preventing falls in hospitalized patients: State of the science. Clinics in Geriatric Medicine35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007

Shaw, L., Kiegaldie, D., & Farlie, M. K. (2020). Education interventions for health professionals on falls prevention in health care settings: A 10-year scoping review. BMC Geriatrics20, 460. https://doi.org/10.1186/s12877-020-01819-x 

Stathopoulos, D., Ekvall Hansson, E., & Stigmar, K. (2021). Exploring the environment behind in-patient falls and their relation to hospital overcrowdedness—A register-based observational study. International Journal of Environmental Research and Public Health18(20), 10742. https://doi.org/10.3390/ijerph182010742 

Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2022). Fall prevention practices and implementation strategies: Examining consistency across hospital units. Journal of Patient Safety18(1), e236–e242. https://doi.org/10.1097/PTS.0000000000000758 



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