Process improvement methodology led to a 40 percent reduction in patient falls at Broward Health Imperial Point after just one year.

Imperial Point nursing staff recognized the ripe opportunity to improve care when their fall rate hit roughly 3.2 per 1,000 patient days. Fall prevention became a top priority and an interdisciplinary team – with the support of hospital leadership – was tasked with applying Six Sigma techniques to inform new processes.

Process Improvement Step 1: Assess

Before developing an action plan, the team

  • conducted a root cause analysis;
  • surveyed nurses on all shifts;
  • created a process map; and
  • analyzed incident reports.

They found half of their patients fell during bathroom activities and 20 percent of the patients who fell were not identified as being at risk.

Process Improvement Step 2: Identify

The team then identified the following as contributing to the high fall rate:

  • incorrect assessments
  • lack of determining at-risk patients
  • inconsistent nurse judgment about when to initiate fall prevention protocol
  • inadequate education on falls
  • lack of patient and family participation in prevention efforts
  • inconsistent bathroom supervision for patients
  • variable bed alarm functionality

Process Improvement Step 3: Improve

Based on these findings, the team developed an improvement plan that included

  • educating nurses and patients about fall risk;
  • unit and facility safety huddles;
  • immediate evaluation of events after a fall occurs;
  • scripted teach back, with patients explaining to the nurse why they are a fall risk;
  • scripted rounding;
  • requiring nurses to stay with at-risk patients in the bathroom; and
  • enhanced bed alarm connectivity with call bell system.

Within one year of instituting the changes, Imperial Point’s fall rate dropped to 1.97 per 1,000 patient days, or roughly 40 percent. These results were recently shared at the 2015 Annual Nurses Improving Care for Healthsystem Elders Conference in Orlando, Fla.