by the Staff of Kings Harbor Multicare Center, Bronx, New York
Data for 2002 from the Center for Health Systems Research and Analysis (CHSRA) at the University of Wisconsin'Madison indicate that New York State long-term care facilities had 14.6% of their resident populations experience a fall. The prevalence of falls and the challenges they present are not new to the industry. According to national data, falls are the underlying cause of death each year for almost 10,000 patients over age 65. Studies suggest that falls are one of the costliest categories of injuries among older persons. The cost involves not only the financial impact but also the emotional impact on the person. Fear of falling may lead to a resident's decreased confidence in his or her ability to ambulate safely and, potentially, to further functional decline. In turn, this may lead to depression and feelings of helplessness and social isolation. A fall affects not only the resident, but the family, as well, who witness their loved one's pain and decrease in functional status.
Resident falls are related to multiple factors, and no one intervention on its own may be successful if other relevant factors aren't identified. Based on a review of clinical and statistical data, quality indicators, resident assessments and resident occurrences, and quality-assurance reports, our facility decided to focus on a project to improve resident safety and decrease the overall number of resident falls.
Our facility consists of four populations, each with different needs. Two of the populations are largely mobile, although many of these residents have cognitive impairment. Three subacute units have clients/residents who, although often independent prior to hospitalization, now have limitations they may not fully recognize. Because these factors contribute to a high risk for falls, there is facility-wide potential to involve all residents in a falls-prevention program. Figure 1. Timeline-December 2002 through December 2003. Click on image to enlarge view. Planning and Implementation Strategies
In 1998, a newly formed management team that included the Assistant Administrator, Director of Nursing, Director of Rehabilitation, and Director of Quality Assurance/Staff Development reviewed many areas of the organization for possible quality-improvement projects. The area of "resident occurrences" (unexpected, unintended events that may or do cause injury) was one. We began developing a risk management team; it included the Director of Rehabilitation, who headed the team; nursing staff; and several other staff members. During the years since, it has grown to include representatives of Social Services, Dietary, Housekeeping, Recreation, Engineering and, most recently, the Medical Director.
We decided in the last quarter of 2002 to develop a new process to further evaluate our systems and processes. We wanted to improve resident safety and, more specifically, focus on decreasing the number of resident falls, rather than focusing on the broader target of reducing resident accidents and incidents. Our overall objective was to decrease falls by approximately 20% in one year.
The project began in January 2003 and continued through the end of the year. We used a process published by the Joint Commission on Accreditation of Healthcare Organizations, as well as established quality-assurance principles. Based on the concept of Failure Mode and Effects Analysis (FMEA), strategies involved creating a timeline (figure 1), flowcharts (figure 2), a focus team with specific roles and responsibilities, and audit tools to help measure the outcome.
The use of flowcharts allowed us to analyze any areas that might cause or lead to failure (in this case, falls). These identified areas could then be changed or enhanced, as appropriate. Through the use of the flowcharts and the FMEA model, we were able to redesign our falls-management process and put into effect a new approach that would hopefully lead to the desired reduction.
Each potential failure mode of the process was carefully identified, prioritized, and analyzed through the FMEA process (table 1). We focused on the following priority problem areas:
- Standardized preventive interventions that were sometimes ineffective
- Inconsistent, at times poorly completed, investigations and corresponding documentation
- Inadequate review at risk management meetings
- Ineffective resident education/reinforcement
- Inadequate reevaluation of revised care plans' effectiveness
- A need for enhanced staff education
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