| Primary Author: | Judith Ann Moran, RN, DNSc, NE-BC |
| Organization: | Huntington Hospital |
Abstract
Purpose
The purpose of this quality improvement project is to describe how to motivate staff to use innovative, evidence-based nursing strategies effective at preventing patient falls within the complex adaptive system of the modern day hospital environment.
Background
Patient Falls are the most common adverse event reported in hospitals. Of those who fall, 25% suffer injuries which increase morbidity, mortality and cost. Patient Falls is an important nursing sensitive indicator of the quality of care provided to patients. Research has identified positive relationships between certain nursing “best practices” and decreased patient falls, such as: IPASS (Team STEPPS) to conduct bedside RN:RN handoff report at change-of-shift; proactive hourly rounding; staying with high risk patients while in the bathroom; bed and chair alarms, etc. Nevertheless, little is known about how best to motivate staff to consistently use EBP fall prevention strategies.
Materials & Methods
The Fall Rate Index (1.89) at a Magnet-designated community hospital was consistently below the NDNQI Benchmark of 3.74. Nevertheless, a “shared mental model” was needed to change existing culture and further improve fall-related outcomes. This strategy is described in Team STEPPS, a patient safety program aimed at improving teamwork and communication among care providers. In 2008, a newly appointed Nurse Manager became interested in using the concept of transparent, public reporting of quality data as an innovative way to create a “shared mental model” among her staff members. She posted the number of “Fall Free Days” at the nursing station. Although faced with opposition from the nursing and medical staff, she persevered in her endeavor.
Results
Since initiating the “Fall Free Days” strategy, patient falls have decreased 40% and related injuries are minimal. Every clinical unit now posts their number of “Fall Free Days” as a fall prevention best practice. In 2010, the 22-bed Orthopedic Unit only 5 falls, none with injuries, and experienced a remarkable stretch of 205 days without a fall!
Conclusion
Public reporting of quality data can be utilized as a continuous learning opportunity in the complex adaptive system of the modern day hospital environment. It serves as a catalyst which motivates staff to consistently use evidence-based nursing strategies to safeguard patients and achieve high quality outcomes.
© Improvement Science Research Network, 2011