(withdrawn) Fall-O The Process! Fall Prevention Program

Purpose:
To reduce the fall rate by improving overall compliance with the fall prevention program strategies from zero percent to 90%. The baseline fall rate was 5.55 (per 1000 patient days) and compliance with the fall prevention program strategies zero percent.

Significance:
Patient falls can result in injury or death. Patient falls can impact length of stay, cost of care, and reimbursement. Joint Commission Accredited hospitals are required to assess and manage patient's risks for falls and implement risk reduction interventions.

Strategy and Implementation:
A Lean Six Sigma project was initiated. Define: The fall program policy, electronic medical record (EMR), & interventions did not match. A survey of nurses revealed that 63.8% of nurses rated themselves as proficient to complete the Morse Fall Scale; and 49% of nurses were not reassessing fall risk after a change in patient condition. In a survey of 104 patients, 64% reported they did not receive education on fall prevention. Analyze: Of the 19 best practice fall prevention strategies identified from the hospital policy, 6 critical elements were not available in the EMR for the nurse to document. Improve: A Workout of frontline staff was conducted; resulting in a revised fall prevention program strategies with congruence between the policy, signage & patient education & EMR. The theme Fall-O the Process was used to motivate the staff during staff education & implementation of the project. Ms. Fallen Down & Ms. Slippin O'DeFlore made rounds to reward staff for Fall-Oing the process.

Evaluation:
Post implementation, 1) the Sigma Score is 2.1 or a 72.6% improvement in compliance with the fall prevention program strategies, 2) organizational fall rates has improved to 5.07 and 3) 98% of patients received patient fall education.

Implications for Practice:
Evidence indicates that a fall prevention program that utilizes a evidence–based fall risk measurement tool & interventions, a standardized process where policy, process, structure, charting, & education are streamlined and match can result in a reduction of patient falls.