Leadership Plan
Reducing fall injuries and deaths associated with falls is the ultimate outcome wanted by leaders and their respective organizations. While all leaders strive to transform culture, advance patient safety and reduce patient harm, reducing patient falls requires cutting the invisible rubber bands of traditional actions and focus on elevation of their leadership and their health system to precision performance.
Leaders and their governing boards must:
1. Balance the tension between production efficiency, reliability and patient safety. Research supports the correlation of staffing mixes, team work, and communication as a major influencer on falls management and injury reduction.
2. Create and sustain trust throughout the organization. High trust organizations have a preoccupation with failure to advance patient safety. Leaders must create a culture that reduces fear of reprisal and promotes open dialogue and organizational learning.
3. Actively managing the process of change and transformation. Leaders must be committed and stay committed to reducing falls by clearly communicating their commitment, strategies and learnings.
4. Involving employees through the improvement process, including debriefs, analysis of data, development of action plans and advancement of safety
5. Use knowledge management practices to establish within the organization learning and promote innovation. Leaders must apply knowledge and learnings to new and existing physical environment, workflow, practice changes and decision making.
6. Utilize patient and family councils to redesign education, physical environment and patient/family partnerships to reduce injuries and harm.
Practice Plan
Researchers agree that falls management and injury reduction strategies must acknowledge complexity and be multifocal, multicomponent in development and nature. have system nature. have system
An effective practice plan needs to start with process steps before moving into application into the practice setting. In the Preventing Falls In Hospitals, A Toolkit for Improving Quality Care (reference AHRQ document) (add link to document) a detailed analysis for leaders to use is given as a toolkit. The following is a summation of the steps to be taken before design and implementation of actual program.
1. Determine the current state of fall program. Look for standardization and points of where there is variation
2. Determine and understand the organizational context of the practice in falls management and injury reduction. Have there been prior efforts to improve practice? What lessons can be learned and barriers identified to address beforehand?
3. Determine who prescribe and review medications. Do those involved in medication regimes, including administration understand their roles in fall management and injury reduction?
4. Determine how is information about patient fall risk factors communicated, documented and shared to assure appropriate actions and culture of safety.
5. Determine current processes within specific departments or units. Consider using such tools as process mapping to understand current practice and where actions could or should be happening for falls management and injury reduction. While process mapping is time consuming, examining each step can give critical insight into not only how particular care processes are being carried out but can lead to further discussion on how they should be carried out.
6. Determine how to integrate practice changes in current workflows and rituals within the care settings.
7. Determine the current state of staff knowledge and understanding of falls management and injury reduction. Exploring possible biases bout conducting risk assessments, interventions and perspectives about falls.
�8Sh
Practice Plan
Researchers agree that falls management and injury reduction strategies must acknowledge complexity and be multifocal, multicomponent in nature.
An effective practice plan needs to start with process steps before moving into application into the practice setting. In the Preventing Falls In Hospitals, A Toolkit for Improving Quality Care (reference AHRQ document) (add link to document) a detailed analysis for leaders to use is given as a toolkit. The following is a summation of the steps to be taken before design and implementation of actual program.
1. Determine the current state of fall program. Look for standardization and points of where there is variation
2. Determine and understand the organizational context of the practice in falls management and injury reduction. Have there been prior efforts to improve practice? What lessons can be learned and barriers identified to address beforehand?
3. Determine who prescribe and review medications. Do those involved in medication regimes, including administration understand their roles in fall management and injury reduction?
4. Determine how is information about patient fall risk factors communicated, documented and shared to assure appropriate actions and culture of safety.
5. Determine current processes within specific departments or units. Consider using such tools as process mapping to understand current practice and where actions could or should be happening for falls management and injury reduction. While process mapping is time consuming, examining each step can give critical insight into not only how particular care processes are being carried out but can lead to further discussion on how they should be carried out.
6. Determine how to integrate practice changes in current workflows and rituals within the care settings.
7. Determine the current state of staff knowledge and understanding of falls management and injury reduction. Exploring possible biases bout conducting risk assessments, interventions and perspectives about falls.
�8Sh