August 18, 2017
Change Management Helps Reduce Falls
Background and the start of a solution
Weston County Health Services successfully eliminated resident falls with major injury by using a change management methodology and a team-based approach.
Falls in nursing homes can often have serious consequences. One out of five falls causes a serious injury such as broken bones or a head injury, according to the American Journal of Public Health. Falls are also a leading cause of traumatic brain injuries in seniors.
“We want every resident at Weston County Health Services to receive the best possible care, and reducing the potential for major injuries through fall prevention is one area we knew we could improve,” said JoAnn Farnsworth, “so we rolled up our sleeves and got to work.”
In December of 2015, Weston had 9 falls with major injuries for that month alone. By the end of 2016, the facility did not have any falls with major injuries for numerous months in a row.
Track, change, test and verify
The Weston team’s first step was to educate nursing staff on fall prevention interventions. Educational handouts, brochures and posters focused on the results from pre- and post-intervention audits and served as a tutorial on best practices.
Next, the facility implemented changes in its processes that could reduce potential falls. The Weston team reported and tracked all falls. When a fall occurred, the team conducted post-fall huddles and immediately implemented interventions for rapid change. The team then reviewed the findings at weekly interdisciplinary meetings to see whether an individualized change produced a favorable outcome. Weston slowly saw results through changing, testing and verifying each individual outcome. Solutions were shared and applied to other residents when possible, and the team also sought help from family members to help determine the root causes of falls.
Weston implemented the following individualized interventions that produced results:
– Moved a resident’s bed to allow him/her to get out of bed on the opposite side
– Purchased a new chair for positioning and safe mobility without sliding off the chair
– Placed back-up brakes for residents who forgot to put on wheelchair brakes
– Created individualized toileting schedules
– Placed flat mats at bedsides
– Created a performance improvement project (PIP) on call light response times
– Created a quality assurance plan for call lights to be within reach at all times
Weston used the Centers for Medicare & Medicaid Services (CMS) Quality Measures Report provided by Mountain-Pacific Quality Health as a tracking tool. Through a methodical process of trial and err, Weston successfully used change management to produce favorable outcomes to practically eliminate fall-related major injuries in its facility. Weston’s fall rate with major injuries is now well below state and national standards.
“Our entire staff is very proud of this accomplishment,” Farnsworth said. “When a resident gets hurt, we feel terrible. Our residents’ quality of life is very important to us. Weston Manor’s front-line staff has been the key to our success and we appreciate their hard work!”
About Mountain-Pacific—Mountain-Pacific is a 501(c)(3) nonprofit corporation and holds federal and state contracts that allow them to oversee the quality of care for Medicare and Medicaid members. Mountain-Pacific works within its region (Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands) to help improve the delivery of health care and the systems that provide it. Mountain-Pacific’s goal is to increase access to high-quality health care that is affordable, safe and of value to the patients they serve. www.mpqhf.org