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NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

Student Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name:


Planning for Change: A Leader’s Vision 

Esteemed administrators and stakeholders, my name is ________, and I would like to welcome you all to today’s presentation. I will outline the quality and safety issues of inpatient falls in ___________ (mention the organization). Through this presentation, I aim to discuss the proposed plan to enhance the quality and safety culture within the organization. 

Background of Systemic Problem 

Inpatient falls represent a systemic problem within ___________ (mention the organization), accounting for 30 fall incidents per 1,000 patient days. This problem poses significant risks to patient safety and well-being, such as fall-related injuries, additional costs, psychological distress, and poor quality of life (LeLaurin & Shorr, 2020). Along with the intrinsic contributing factors, some performance gaps reveal insufficient preventive measures, a lack of safety culture, and reduced staff adherence to fall prevention protocols within the organization. Thus, a quality and safety plan is proposed to reduce fall rates and alleviate poor consequences.

Plan to Enhance a Culture of Safety Within Our Organization

The practice changes designed for __________(mention the organization) aims to increase fall prevention efforts, reduce inpatient fall rates, improve patients experiences, and enhance a safety culture within the organization. These fundamental changes include: 

Comprehensive Fall Risk Assessment Protocols

This involves the use of standardized protocols for fall risk assessment. According to Strini et al. (2021), standardized fall risk assessment protocols, such as the Morse Fall Scale and Hendrich II Fall Risk Model, are beneficial for organizations to identify high-risk populations, guiding preventive efforts. Through this practice change, we aim to enhance fall risk assessment practices among healthcare providers at the time of admission and during patients’ stay in the hospital to make necessary modifications based on patients’ conditions. 

Staff Education and Training

Next, the plan is to implement educational interventions. These staff training and education initiatives will improve the quality of staff practices, primarily related to inpatient falls. By creating awareness, the organization can close the performance gap of non-compliance with fall prevention protocols (Shaw et al., 2020). Ultimately, these training and education programs will enhance patient safety and reduce adverse outcomes.

Multidisciplinary Fall Prevention Teams

Lastly, the plan entails the establishment of an interprofessional fall prevention team comprising physicians, nurses, pharmacists, physical therapists, and environmental specialists. These team members will provide diverse expertise to guide fall prevention interventions tailored to patients’ needs and organizational objectives. These teams will collaboratively facilitate comprehensive fall risk assessment, implement interventions, and monitor the efforts for ongoing quality improvement (Gemmeke et al., 2022). 

Existing Organizational Functions, Processes, and Behaviors 

Now, we will discuss how the existing organizational functions, procedures, norms, policies, and staff behaviors affect the quality of care and patient safety within our organization, significantly augmenting in-patient fall rates. The lack of comprehensive fall risk assessment procedures is a primary organizational lapse that increases in-patient falls. For instance, inconsistent fall risk assessment protocols may result in missed opportunities to effectively identify and address patient fall risks (Appeadu & Bordoni, 2023). Additionally, environmental factors such as inadequate lighting and crowded walkways are hazardous practices within the organization, heightening fall risk for high-risk patient populations. Similarly, behavioral inefficiencies of communication gaps among health providers and lack of staff adherence to fall prevention strategies increase the likelihood of in-patient falls. This results from insufficient practices and coordination failures (Turner et al., 2022). 

Addressing these aspects can contribute to building reliability and high-performing organizations by focusing on several key strategies, such as standardizing fall risk assessment protocols and ensuring comprehensive staff training on fall prevention strategies. Secondly, creating a sense of accountability and continuous learning by fostering open communication channels and interdisciplinary collaboration among healthcare teams. Additionally, making environmental modifications to create safer care environments and mitigate fall risk factors (Stathopoulos et al., 2021). 

Knowledge Gaps and Areas of Uncertainty 

Despite knowing the organization’s functions and behaviors impacting quality and safety, there remain knowledge gaps and areas of uncertainty. The knowledge gaps exist related to the best practices that have positively affected the organization. There are uncertainties surrounding the optimal utilization of technology in identifying fall risk factors and guiding preventive measures. Moreover, there are unanswered questions regarding the leadership commitment to fostering a safe and supportive environment for fall prevention efforts. Addressing the knowledge lapses will result in the effective implementation of the proposed plan. 

Current Outcome Measures Related to Quality and Safety

Enhancing the quality of care and patient safety culture is continuous, requiring ongoing monitoring and evaluation. Thus, the organization should focus on particular outcome measures to collect quantifiable data on in-patient falls and develop interventions accordingly. These outcome measures are fall rates, fall-related injuries, and costs. Here, we will discuss these outcome measures, elaborating on their strengths and weaknesses.  

Fall Rates

The numerical data that evaluates the number of falls per patient day in a patient population for a specified time is called the fall rate (AHRQ, n.d.). This outcome measure is advantageous as it enables the organization to monitor fall patterns, recognize high-risk patients, and monitor the effectiveness of fall prevention errors. Yet, its weakness is that its accuracy depends on precise reporting and may encounter variations due to underreporting. 

Fall-Related Injuries

Kenis et al. (2022) emphasize that fall-related injuries are a valuable outcome measure for assessing the severity of in-patient falls. This outcome measure is substantial as it helps identify the damage caused by in-patient falls, guiding the need for more sustainable and robust preventive interventions. However, a limitation of this measure lies in the inconsistency and variability in reporting and categorizing injuries. Fall-related injuries may result in less reliable data, necessitating a nuanced data collection and analysis approach. 


This outcome measure evaluates the financial impact of inpatient falls. Assessing the cost of inpatient falls is valuable as it helps organizations plan resource allocation and invest in more comprehensive fall prevention efforts (Ağartioğlu Kundakçi et al., 2020). Nevertheless, this outcome measure challenges the stakeholders to identify the sole reason for healthcare costs, as additional expenditures may be associated with other factors. 

Steps Needed to Achieve Improved Outcomes

I will elaborate on the steps needed to improve outcomes through each practice change described earlier. 

Comprehensive Fall Risk Assessment Protocols

The steps in standardizing fall risk assessment protocols include reviewing the existing fall risk assessment tools and protocols to identify strengths and weaknesses. Next, select evidence-based fall risk assessment tools such as the Morse Fall Scale or Hendrich II Fall Risk Model. This selection should be based on its applicability and effectiveness within similar practice settings (Strini et al., 2021). Additionally, healthcare staff should be trained to administer fall risk assessments and interpret assessment results adequately.

The last step is incorporating standardized fall risk assessment protocols into admission procedures and regular patient assessments throughout their hospital stay. This plan assumes that accurate fall risk assessment leads to precise identification of patients at high risk of falls, ensures consistency in care delivery, and improves the effectiveness of preventive interventions. Furthermore, regular fall risk assessments based on patient conditions facilitate proactive management of fall risk factors, reducing the likelihood of falls (Appeadu & Bordoni, 2023). 

Staff Education and Training

These training and education programs should include these action steps: 

  1. Assessment of current staff knowledge and training needs. 
  2. Development of a comprehensive and evidence-based fall prevention curriculum covering fall risk factors, assessment techniques, preventive strategies, and appropriate responses to fall events.
  3. Conducting regular educational sessions, along with hands-on practices and simulations.
  4. Offer ongoing education and updates to inform staff of best practices and emerging evidence in fall prevention.
  5. Monitoring staff adherence to the learned concepts and fall prevention measures. 

This plan assumes that well-trained healthcare professionals are better equipped to recognize risk factors and respond effectively to fall events. Moreover, regular training fosters accountability and continuous learning, an essential organizational process in high-performing organizations (Mataac, 2023). 

Multidisciplinary Fall Prevention Teams

Creating multidisciplinary fall prevention teams is essential to enhance collaboration and coordination in fall prevention efforts. Critical steps for effective implementation of these teams include identifying essential stakeholders. This step is crucial as an effective team will efficiently perform fall prevention, reducing fall rates (Gemmeke et al., 2022). The next step is establishing clear roles and responsibilities for team members, which include risk assessment, intervention planning, and monitoring and evaluation. Thirdly, holding regular team meetings and creating effective communication channels is imperative to discuss and identify opportunities for improvement.

Regular team meetings and effective communication are presumed to promote a culture of continuous learning and quality improvement. This step is crucial to foster interprofessional collaboration among the team members (Rawlinson et al., 2021), assuming that this collaboration allows for a comprehensive and holistic approach to fall prevention. Lastly, evaluating interventions’ effectiveness and adjusting strategies based on feedback and performance metrics is vital. 

Future Vision and Nurse Leaders’ Role in Sustaining Quality and Safety Culture

In envisioning the future of our organization, we foresee a healthcare environment where patient safety is paramount, and healthcare teams are actively engaged in fall prevention efforts. As a learning organization, we continuously strive for improvement and innovation in fall prevention practices. Thus, we envision that our staff are empowered to take ownership of fall prevention initiatives, contributing their expertise and ideas to developing and implementing evidence-based strategies.

Nurse leaders play a crucial role in developing the future potential of our organization and sustaining a culture of quality and safety. They are the champions of patient safety and thus advocate for fall prevention efforts (Gifford et al., 2019). They guide and support nursing staff to take an active role in fall prevention initiatives and foster a sense of accountability for patient safety. Moreover, they are crucial in fostering interdisciplinary collaboration to assess fall risk, implement preventive measures, and monitor patient outcomes. As a result of these collective efforts, our organization will achieve significant reductions in fall rates and fall-related injuries, enhancing patient safety and well-being. Looking ahead, we remain dedicated to sustaining this culture of excellence and continuously improving our fall prevention practices to meet the evolving needs of our patients and community.


In conclusion, in-patient falls remain a significant systemic problem within _________ (mention the organization’s name). Thus, to address the issue and close the performance gap, we require a quality and safety improvement plan based on implementing comprehensive fall risk assessment protocols, staff education, and multidisciplinary fall prevention teams. The implementation plan requires several steps to ensure seamless execution. Moreover, the organization must monitor and evaluate outcome measures (fall rates, fall-related injuries, and costs) to assess the effectiveness of these interventions. This plan underscores the ongoing commitment to excellence in healthcare and the collective efforts of healthcare teams and leadership, which are required to create safer healthcare facilities for patients.


Ağartioğlu Kundakçi, G., Yılmaz, M., & Sözmen, M. K. (2020). Determination of the costs of falls in older people according to the decision tree model. Archives of Gerontology and Geriatrics87, 104007. https://doi.org/10.1016/j.archger.2019.104007 

Appeadu, M. K., & Bordoni, B. (2023). Falls and fall prevention in older adults. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK560761/ 

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 

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 4 Planning for Change: A Leader’s Vision

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

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 

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 

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

NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision

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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