Standing Up to Falls
“Why do we fall? So we can learn to pick ourselves back up.” That inspirational quote is designed to focus on lessons that can be learned in order to move forward effectively and ultimately succeed.
When a fall is approached as an opportunity to learn, new knowledge is gained, informing changes that can lead to improvement. Learning is at the heart of improvement, innovation, and growth. But when a patient fall is treated as a failure, the learning stops.
Despite advancements in technology and methodology, hundreds of thousands of patients continue to fall in hospitals each year, and 30%–35% of them suffer injuries. On average, 358 patients fall each year in a typical 200-bed hospital, resulting in approximately 117 injuries. The implementation of evidence-based best practices has not eliminated patient falls in healthcare settings. In order for patients to stop falling, a change in approach is necessary.
Patient falls represent a chronic, complex problem, demonstrating that healthcare is not yet highly reliable. But falls can be addressed by adopting the mindset and methodologies of other industries that have gone from low to high reliability. In healthcare, we can learn how to approach safety from high-reliability organizations (HRO), and we can learn how to approach improvement from manufacturing industries.
Understanding HROs
An HRO is one that has succeeded in avoiding catastrophes in an environment where accidents can be expected due to risk factors and complexity. The amusement park, commercial airline, and nuclear power industries are often considered HROs because of their remarkable lack of adverse events.
HROs avoid accidents, first and foremost, by acknowledging how much they do not know and establishing cultures of learning. Everyone from the front lines to the boardroom takes responsibility for safety, which requires trust. In a trusting organization, management and staff recognize that everyone across the organization has expertise and contributes to patient care. Peers hold each other accountable. Staff members feel comfortable reporting errors and variations in care to their supervisors. Everyone is accountable for safety and behaves accordingly.
These organizations prize the identification of errors and close calls because, through a careful analysis of what occurred before these events took place, lessons can be extracted. Such lessons point to specific weaknesses in safety protocols or procedures that can be remedied to reduce the risk of future failures. There is a focus on prevention, not reaction. The further upstream the problem is, the more important it is to fix.
A robust approach to improvement
Few individuals have had more impact on modern industry than engineer W. E. Deming. In Japan, he’s considered a miracle worker based on his work with Japanese industrial leaders after World War II. In the United States, he’s best known for his 14 Points and what he called the System of Profound Knowledge. Deming focused on data and quality in ways few before him had, and the results were profound.
Today, companies like Motorola, Toyota, and General Electric internalize Deming’s approach to management and performance—using data in a systematic manner, gathering stakeholders across silos, listening to the voice of the customer, and showing respect for all workers. Improvement becomes the way everyone does their work through the deployment of experts and training for all staff. The programmatic infrastructure for improvement is integrated into human resources, and key metrics for the effectiveness of the program are reported to the board.
A blend of Lean, Six Sigma, and change management methodologies and tools is known as Robust Process Improvement® (RPI®). RPI is a systematic, data-driven approach to learning, change, and improvement. These problem-solving methods are critical to addressing complex quality problems, like falls.
Getting to zero falls
In 2011, Kaiser Permanente San Diego asked itself the simple, yet complex question: Could it prevent all falls hospitalwide? To find out, it launched its “No One Walks Alone” program, with the ambitious goal of zero falls hospitalwide by November 2012.
As it turns out, Kaiser Permanente didn’t need the full year; even better, the organization went through a complete culture change. Key to the transformation was leadership commitment, collaboration, and simplification.
When faced with a problem, many hospitals get a team together in a room, brainstorm about the problem, and then implement solutions that often are ill fitted to the local environment. This leads to project fatigue and a lack of sustainability. The Kaiser Permanente San Diego team, on the other hand, simplified everything. Their journey to simplification started slowly. They took time to look at and measure all the key variables, from bed placement to mobility issues and medications, to determine how, why, and when patients fall. Through measurement, the team determined that unassisted patients accounted for 86% of falls in the project area. Then they drilled down to a simple solution—vigilance whenever any patient walked, carried out across all disciplines. Anyone in a patient’s room—be it an environmental services staff member, physician, nutritionist, lab technician, or physical therapist—was responsible for ensuring the patient did not walk alone. The staff at the organization also made the key distinction of identifying all inpatients as fall risks.
With this approach, which was a change from prior fall prevention efforts, Kaiser Permanente San Diego successfully addressed falls.
Kaiser Permanente San Diego was one of seven participating hospitals in the Joint Commission Center for Transforming Healthcare’s Preventing Falls with Injury project. In partnership with other Center organizations, each organization used RPI with total facilitywide accountability in order to prevent falls. The Center’s participants, which include some of the nation’s leading hospitals and health systems, all had experience using these robust concepts and tools.
Throughout the project, the participating organizations used DMAIC (Define, Measure, Analyze, Improve, Control) as the problem-solving methodology to determine the contributing factors to falls, with each organization uncovering its own unique factors. Detailed data was gathered on all falls for the baseline period and then analyzed. Measuring these factors is critical to identifying the solutions that lead to sustainability. The discoveries of specific, unanticipated contributing factors were labeled as “aha” moments. To address each factor, the organizations created targeted solutions to prevent falls among adult hospital inpatients, such as creating staff awareness, empowering patients to take an active role in their safety, and using a validated fall risk assessment tool.
The operational definitions, measurement systems, and solutions developed by the participating organizations were validated in other healthcare organizations and then used by the Center to develop the Targeted Solutions Tool® (TST®) for Preventing Falls. The TST is an online application that guides a project leader through a robust approach to preventing falls, based on RPI methodology. The targeted solutions, which were thoroughly tested and proven effective during the project, are strategies developed to mitigate contributing factors. In all, the hospitals and the Center created a total of 21 targeted solutions during the course of the project. As solutions were developed, the hospitals discovered that falls prevention was not a set of disparate and unrelated activities. Instead, preventing falls was a key strategy in the prevention of patient harm.
The initial hospitals participating in the project reduced the falls-with-injury rate by 62% and the overall falls rate by 35%, far surpassing the project’s goals. These are exciting numbers not only for the Joint Commission Center for Transforming Healthcare, but for patients and healthcare organizations. Applying these numbers to a typical 200-bed hospital, fall prevention efforts could reduce the number of patients injured in falls from 117 to 45 and save approximately $1 million annually.
Preventing falls requires organizations to become learning organizations. Learning organizations prize failures as opportunities to move forward and improve. A data-driven, robust approach to understanding individual falls is necessary for healthcare organizations to become highly reliable and eliminate patient harm.
Erin DuPree is chief medical officer and vice president for the Joint Commission Center for Transforming Healthcare. She may be contacted at edupree@jointcommission.org.