Preventing Falls in Hospitals A Toolkit for Improving Quality of Care The information in this toolkit is intended to assist service providers and hospitals in developing falls prevention protocols. This toolkit is intended as a reference and not as a substitute for professional judgment. The opinions expressed in this document are those of the authors and do not necessarily reflect the views of AHRQ. No statement in this toolkit should be construed as an official position of AHRQ or the U.S. Department of Health and Human Services. In addition, AHRQ or U.S. Department of Health and Human Services endorsement of any derivative product may not be stated or implied. Preventing Falls in Hospitals A Toolkit for Improving Quality of Care Prepared for: Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Prepared by: RAND Corporation Boston University School of Public Health ECRI Institute Contract No. HHSA290201000017I TO #1 AHRQ Publication No. 13-0015-EF January 2013 Authors RAND Corporation David A. Ganz, M.D., Ph.D., VA Greater Los Angeles Healthcare System, University of California at Los Angeles, and RAND Corporation Christina Huang, M.P.H., RAND Corporation Debra Saliba, M.D., M.P.H., VA Greater Los Angeles Healthcare System, UCLA/JH Borun Center for Gerontological Research, and RAND Corporation Victoria Shier, M.P.A., RAND Corporation Boston University School of Public Health Dan Berlowitz, M.D., M.P.H., Bedford VA Hospital and Boston University School of Public Health Carol VanDeusen Lukas, Ed.D., VA Boston Healthcare System and Boston University School of Public Health ECRI Institute Kathryn Pelczarski, B.S. Karen Schoelles, M.D., S.M. Linda C. Wallace, M.S.N., B.S.N. Patricia Neumann, R.N., M.S. This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated. Suggested citation: Ganz DA, Huang C, Saliba D, et al. Preventing falls in hospitals: a toolkit for improving quality of care. (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI Institute under Contract No. HHSA290201000017I TO #1.) Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF. ii Contents Roadmap ..........................................................................................................................................v Acknowledgments.......................................................................................................................... ix Overview ..........................................................................................................................................1 The Problem of Falls ..................................................................................................................1 The Challenges of Fall Prevention .............................................................................................1 Toolkit Designed for Multiple Audiences .................................................................................2 Implementation Guide Organized To Direct Hospitals Through the Change Process ..............3 Sections of the Guide .................................................................................................................3 Adaptation of the Guide to Your Organization..........................................................................3 Improvement as Puzzle Pieces ...................................................................................................4 Icons .................................................................................................................................................5 1. Are you ready for this change? ....................................................................................................6 1.1. Do organizational members understand why change is needed? ........................................6 1.2. Is there urgency to change? .................................................................................................8 1.3. Does senior administrative leadership support this program? ............................................9 1.4. Who will take ownership of this effort? ...........................................................................11 1.5. What kinds of resources are needed? ................................................................................12 1.6. What if you are not ready for full-scale change? ..............................................................12 1.7. Checklist for assessing readiness for change ....................................................................13 2. How will you manage change? ..................................................................................................14 2.1. How can you set up the Implementation Team for success? ............................................15 2.2. What needs to change and how do you need to redesign it? ............................................19 2.3. How should goals and plans for change be developed? ...................................................25 2.4. Checklist for managing change .........................................................................................26 3. Which fall prevention practices do you want to use? ................................................................27 3.1. Which fall prevention practices should you use? .............................................................28 3.2. What are universal fall precautions and how should they be implemented? ....................30 3.3. What is a standardized assessment of risk factors for falls, and how should this assessment be conducted? ............................................................................................34 3.4. How should identified risk factors be used for fall prevention care planning? ................38 3.5. How should you assess and manage patients after a fall? ................................................46 3.6. How can your hospital incorporate these practices into a fall prevention program? ........49 3.7. What additional resources are available to identify best practices for fall prevention? ...51 3.8. Checklist for best practices ...............................................................................................51 4. How do you implement the fall prevention program in your organization? .............................52 4.1. What roles and responsibilities will staff have in preventing falls? .................................53 4.2. What fall prevention practices go beyond the unit?..........................................................59 4.3. How do you put the new practices into operation? ...........................................................60 4.4. Checklist for implementing best practices ........................................................................67 5. How do you measure fall rates and fall prevention practices? ..................................................68 5.1. How do you measure fall and fall-related injury rates? ....................................................69 5.2. How do you measure fall prevention practices? ...............................................................77 5.3. Checklist for measuring progress......................................................................................80 iii 6. How do you sustain an effective fall prevention program? .......................................................81 6.1. Who will be responsible for sustaining active fall prevention efforts on an ongoing basis? .........................................................................................................82 6.2. How will you continue to monitor fall rates and fall prevention care processes? ............82 6.3. What types of ongoing organizational support do you need to keep the new practices in place? ........................................................................................................83 6.4. How can you reinforce the desired results? ......................................................................84 6.5. Summary ...........................................................................................................................87 7. Tools and Resources ..................................................................................................................89 Appendix: Bibliography of Studies Implementing Fall Prevention Practices .............................185 iv Roadmap Who Should Use The Section Action Steps Tool That Supports Action Tool Overview Enlist support of senior leaders Tool ØA, Introduction and Overview for Senior manager Stakeholders Section 1 Are you ready for this change? 1.1 Assess the culture of safety in your Tool 1A, Hospital Survey on Patient Safety Culture All interdisciplinary hospital team members 1.2 Evaluate current organizational Tool 1B, Stakeholder Analysis Implementation Team attention to falls leader 1.3 Assess and develop leadership Tool 1C, Leadership Support Assessment Implementation Team support for the fall prevention leader program Tool 1D, Business Case Form 1.5 Identify resources that are available Tool 1E, Resource Needs Assessment Implementation Team and resources that are needed leader 1.7 Assess your progress on completing Tool 1F, Organizational Readiness Checklist Implementation Team readiness for change activities leader Section 2 How will you manage change? 2.1 Identify your Implementation Team Tool 2A, Interdisciplinary