UC Davis

Falls, like other hospital-acquired conditions such as pneumonia, pressure ulcer, and catheter-associated urinary tract infections, are preventable. There are many published scholarly works explaining why falls happen and what organizations can do to help prevent them. However, a successful and sustainable fall prevention program in the acute care setting remains elusive. This thesis describes a proposal for a Quality Improvement Project to implement a multicomponent fall prevention strategy in the acute care setting using the Model for Improvement framework from the Institute of Healthcare Improvement (IHI) and IHI’s Framework for Spread. The target setting for the project is three acute care units at a 245-bed Magnet Designated community hospital in Northern California. The data collected from a previous Safety and Mobility Rounding Initiative conducted in two of the organization’s acute care units were considered in selecting evidence-based and patient-centered fall prevention strategies. The proposed Quality Improvement Project focuses on redesigning workflow to successfully integrate proposed interventions and ensuring sustainability through accountability. The strategies proposed include:1) Modifying the current purposeful hourly rounding and scheduled toileting process. 2) Implementing and educating staff on the use of a Banner Mobility Assessment Tool (BMAT) and promoting staff engagement in patient mobility. 3) Replacing the Fall Contract with Fall TIPS (Tailoring Interventions for Patient Safety). 4) Deploying a trained and designated Certified Nursing Assistant (CNA) or Registered Nurse as a Patient Safety and Mobility Rounder. This proposed project was approved by the Institutional Review Board. The proposal was written during the COVID-19 pandemic and was presented to the Acute Care Leadership Team for pilot testing approval in December 2020, when California was at the height of the coronavirus surge. At the time, it was critical for the hospital to activate its “Surge Protocol” and adapt to the rapid changes brought upon by the pandemic. For this reason, pilot testing and implementation of the proposed Quality Improvement Project remains to be determined.