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NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Student Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name:


Outcome Measures, Issues, and Opportunities

In-patient falls are a complex challenge within ________ (mention the organization’s name used in A1 and A2). This report is for stakeholders to detail the outcome measures, performance concerns, and opportunities within the organization. Moreover, it elaborates and outlines a strategy to enhance healthcare quality and patient safety outcomes. This strategy is developed using a change model, ensuring patient care is thoroughly measured. 

Analysis of Organizational Functions, Processes, and Behaviors

High-performing organizations have several vital functions, effective processes, and stakeholders’ behaviors that contribute to patient safety and quality of care, especially in in-patient falls. High-performing organizations have effective administration, prioritizing patient safety and quality of care by incorporating evidence-based practices. This safety and quality culture helps stakeholders prevent in-patient falls and mitigate associated risks, significantly reducing patient harm and improving the quality of care (Bhati et al., 2023). Moreover, high-performing organizations prioritize a culture of accountability and continuous learning (Mataac, 2023). The stakeholders create open communication channels and feedback mechanisms to encourage staff to report incidents, participate in root cause analysis, and actively engage in quality improvement initiatives related to fall prevention. 

However, despite these strengths, specific knowledge gaps and uncertain areas require further information. There may be unanswered questions regarding the effectiveness of specific evidence-based practices in diverse care settings. Moreover, while these organizations successfully achieve positive outcomes in the short term, questions remain regarding the sustainability of these practices. The questions regarding staff readiness to change and improve quality remain there. Furthermore, the availability of resources to implement these practices is a significant concern. Addressing these knowledge gaps and uncertain areas is imperative to develop targeted and functional plans for our organization. 

Organizational Functions, Processes, and Behaviors and Outcome Measures

The aforementioned organizational functions, processes, and behaviors substantially impact the outcome measures identified for in-patient falls in gap analysis. Organizations that prioritize patient safety and quality of care and foster a culture of accountability and continuous learning directly impact fall rates, fall-related injuries, and healthcare costs. Organizations can reduce fall rates by implementing evidence-based practices that promote quality care and patient safety. These practices include comprehensive fall risk assessments, personalized care plans, and environmental safety measures (LeLaurin & Shorr, 2020). 

Similarly, a culture of accountability and continuous learning through open communication channels and feedback mechanisms enables the organization to identify system weaknesses, implement corrective actions, and continuously improve fall prevention strategies. These systemic functionalities support the reduction of fall rates and fall-related injuries. Additionally, prioritizing patient safety and quality of care, encouraging staff to report incidents, and participating in quality improvement initiatives contribute to cost containment efforts. The practices help organizations minimize fall rates and injuries, reducing healthcare expenditures related to extended hospital stays, diagnostic tests, and rehabilitation services (Dykes et al., 2023). 

This determination assumes that evidence-based practices improve patient outcomes, foster patient safety, and reduce costs (Connor et al., 2023). Moreover, it is presumed that leadership commitment and support of administrative functions and processes lead to the availability of adequate resources and quality improvement efforts. Additionally, a supportive and encouraging culture enables healthcare providers to become accountable for their practices, thus enhancing overall performance in fall prevention and patient safety.

Identification of Quality and Safety Outcomes and Measures

The quality and safety outcome measures identified within ________ (mention the organization’s name used in A1 and A2) are fall rates, fall-related injuries, and costs. The table below presents the data related to these outcome measures and preventive strategies to close the performance gap identified in our organization. 

Systemic Problem
Quality and Safety Outcome Measures
Performance Data
Preventive Measures 

In-patient falls

Fall Rates

30 falls per 1,000 patient days

Implement comprehensive fall risk assessment protocols: Conduct standardized fall risk assessments upon admission and regularly throughout the patient’s stay to identify individuals at high risk of falls (Strini et al., 2021).


Fall-related Injuries

40% of in-patient falls resulted in fractures, lacerations, and head injuries

According to Shaw et al. (2020), regular training sessions for healthcare staff on fall prevention strategies, patient supervision techniques, and safe handling practices can reduce falls and fall-related injuries. 



$10,000 per fall-related injury

Establish multidisciplinary fall prevention teams: Create teams of clinicians, physical therapists, environmental specialists, and administrators to develop and implement prevention initiatives collaboratively (Gemmeke et al., 2022). 

Evaluation of the Quality of Data

The data provided in the spreadsheet is taken from the dashboard within the practice settings. This data provides valuable insights into the prevalence of in-patient falls. The data is accurate as our organization implements standardized data collection methods, conducts regular audits, and verifies data integrity through cross-referencing with quality assurance teams. These teams ensure continuous quality improvement efforts and feedback mechanisms are in place to enhance further the accuracy and completeness of data related to in-patient falls. This data is reliable for informing the decision-making process and developing targeted interventions. 

Performance Issues or Opportunities

The performance issues within our organization related to in-patient falls are comprised of insufficient preventive measures and a lack of a culture of patient safety. These are associated with high-performing organizations’ organizational functions, processes, and outcome measures, as discussed earlier. The most significant opportunity lies in prioritizing patient safety and quality of care through effective administration and implementing evidence-based fall prevention measures. This results in reduced fall rates and fall-related adverse outcomes. However, staff adherence to safety protocols remains a challenging and uncertain situation (Vaismoradi et al., 2020). This may impact care delivery and potential gaps in patient safety.

Additionally, while a culture of accountability and continuous learning fosters open communication and encourages staff engagement, there may be hindrances to effective incident reporting and participation in root cause analysis. Staff members may hesitate to report incidents due to fear of retribution or concerns about the effectiveness of the reporting system (Lu et al., 2022). Thus, a concerted effort is required to strengthen organizational processes, promote a culture of safety and transparency, and provide support and resources for staff participation in quality improvement efforts. 

Strategy for Outcome Measurement and Knowledge Sharing

The Plan-Do-Study-Act (PDSA) change model offers a systematic approach to implementing and evaluating changes in healthcare practices. This iterative model ensures continuous quality improvements within healthcare settings. The literature has proven this model successful in implementing quality improvement initiatives related to fall prevention (Boot et al., 2023). Ensuring that all aspects of patient care related to in-patient falls are measured effectively, our organization can adopt a comprehensive strategy guided by the PDSA model.

First, in the “planning” state, the organization should identify the critical areas of improvement, such as the lack of comprehensive fall prevention efforts and safety culture. Then, there must be clear objectives and goals for fall prevention efforts, such as reducing the fall rates by 10%. They must establish a team of stakeholders and define specific outcome measures to evaluate the plan’s effectiveness. These outcome measures include fall rates, fall-related injuries, healthcare costs, and adherence to fall prevention protocols. Additionally, the organization should plan on allocating resources and budget management and develop a timeline for implementing practice changes (Boot et al., 2023). 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Secondly, in the “doing” phase, the organization will implement the practice changes on a small scale. This may include the implementation of comprehensive fall risk protocols, staff education, and fall prevention teams in a specific department with high-risk populations, for example, geriatric wards (LeLaurin & Shorr, 2020). The organization should ensure that all staff members know their roles and responsibilities in fall prevention and that protocols are consistently followed within the pilot department.

In the “studying” phase, the organization should evaluate the effectiveness of the implemented changes within the smaller departments by collecting and analyzing relevant data. This includes monitoring fall rates, tracking fall-related injuries, monitoring the costs associated with these incidents, and assessing staff adherence to fall prevention protocols. The organization should also solicit staff feedback on the relevance of practice changes and identify areas for improvement to make further moderations. 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Finally, in the “acting” phase, the organization makes adjustments based on the findings to optimize fall prevention efforts further and implement these practice changes across all departments within the hospital. The organization should continue to monitor outcomes and iterate on the improvement process to ensure sustained success in preventing in-patient falls (Boot et al., 2023). However, the organization must establish a strategy to foster knowledge sharing and interprofessional collaboration while developing and implementing proposed changes.

Firstly, regular team meetings can serve as platforms for discussing the plan’s progress, sharing insights, and addressing challenges collaboratively (Rawlinson et al., 2021). Additionally, establishing interdisciplinary task forces or committees dedicated to specific improvement initiatives encourages cross-functional collaboration. Furthermore, creating communication channels, such as staff portals and instant messaging, allows staff members from different disciplines to share best practices, ask questions, and seek real-time advice (Rawlinson et al., 2021). By promoting a culture of openness, inclusivity, and collaboration, the organization empowers staff to contribute their expertise, perspectives, and ideas, ultimately enhancing the effectiveness and sustainability of fall prevention efforts. 


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

Boot, M., Allison, J., Maguire, J., & O’Driscoll, G. (2023). QI initiative to reduce the number of in-patient falls in an acute hospital Trust. BMJ Open Quality12(1), e002102. https://doi.org/10.1136/bmjoq-2022-002102 

Connor, L., Dean, J., McNett, M., Tydings, D. M., Shrout, A., Gorsuch, P. F., Hole, A., Moore, L., Brown, R., Melnyk, B. M., & Gallagher-Ford, L. (2023). Evidence-based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review. Worldviews on Evidence-Based Nursing20(1), 6–15. https://doi.org/10.1111/wvn.12621 

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 

Gemmeke, M., Taxis, K., Bouvy, M. L., & Koster, E. S. (2022). Perspectives of primary care providers on multidisciplinary collaboration to prevent medication-related falls. Exploratory Research in Clinical and Social Pharmacy6, 100149. https://doi.org/10.1016/j.rcsop.2022.100149 

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

Lu, L., Ko, Y.-M., Chen, H.-Y., Chueh, J.-W., Chen, P.-Y., & Cooper, C. L. (2022). Patient safety and staff well-being: Organizational culture as a resource. International Journal of Environmental Research and Public Health19(6), 3722. https://doi.org/10.3390/ijerph19063722 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Mataac, C. (2023). Creating high-performance teams in the modern workplace. https://doi.org/10.13140/RG.2.2.13855.16809 

Rawlinson, C., Carron, T., Cohidon, C., Arditi, C., Hong, Q. N., Pluye, P., Peytremann-Bridevaux, I., & Gilles, I. (2021). An overview of reviews on interprofessional collaboration in primary care: Barriers and facilitators. International Journal of Integrated Care21(2), 32. https://doi.org/10.5334/ijic.5589 

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 

Strini, V., Schiavolin, R., & Prendin, A. (2021). Fall risk assessment scales: A systematic literature review. Nursing Reports11(2), 430–443. https://doi.org/10.3390/nursrep11020041

Vaismoradi, M., Tella, S., A. Logan, P., Khakurel, J., & Vizcaya-Moreno, F. (2020). Nurses’ adherence to patient safety principles: A systematic review. International Journal of Environmental Research and Public Health17(6), 2028. https://doi.org/10.3390/ijerph17062028 

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