The Hospital Setting Prevention: Fall in the Elderly

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Falls in the Elderly in the Hospital Setting: A Quality and Safety Issue

  • Falls are the second leading cause of accidental or unintentional injury deaths worldwide (WHO, 2012, para. 1).
  • In the US, 20-30% of falls in the elderly lead to injuries (WHO, 2012, para. 1).
  • Falls in hospitals remains a very common occurrence: up to 60% of all reported incidents (McDonnell & Kerr, 2014, p. 17).
  • Falls in hospitals lead to adverse psychological (primarily stress) and psychological outcomes for patients and healthcare professionals; they are costly for hospitals (Fitzpatrick et al., 2011).
  • Key reasons for hospital falls lack of observation and faulty risk assessment (McDonnell & Kerr, 2014, p. 17).

Proposed Change

  • Establishment of a continuous system of monitoring and improving safety with respect to falls in the elderly in the hospital environment.
  • Key areas: fall risk assessment practices, environment improvement, training, and patient education training (Boltz, 2012; CDC, 2016; Fitzpatrick et al., 2011; McDonnell & Kerr, 2014).
  • It is impossible to suggest a detailed plan without the involvement of the multidisciplinary team with their individual experiences and knowledge (Boltz, 2012, p. 291). The resulting program is to be customized.

Change Theory

  • Organizational change is typically required for healthcare safety and quality improvement (Sutherland, 2013).
  • The key aspect: managing the change (Cameron & Green, 2015; Sutherland, 2013).
  • Kotters Eight Steps Model: a very popular change model (King & Gerard, 2013).

Change Model to Be Applied: Justification and Application

  • The following steps constitute Kotters Eight Steps model (Cameron & Green, 2015, pp. 100-101).
  • Establish a sense of urgency.

    • A preliminary step.
    • Key role: allows realizing the need for change.
    • Involves the evaluation of the existing practices; defines if they are deficient.
    • It provides the basis for the rest of the change and thus is justified.
    • Tools: data gathering and its presentation in leaflets or posters; meetings.
    • Responsibility: volunteering members.
  • Form a powerful guiding coalition.

    • It provides the center for change management and thus is justified.
    • Tools: meetings of the interested members of the multidisciplinary community of the hospital, department, ward.
  • Create a vision.

    • Provides the vision, mission, and strategy for the change; aligns it with the hospitals mission, vision, and strategic goals.
    • It provides the plan for the change and thus is justified.
    • Tools: data gathering, knowledge development, meetings; surveys for stakeholder involvement is a possibility.
    • Responsibility: the coalition.
  • Communicate the vision.

    • Highlights the importance of communication between stakeholders.
    • Ensures the dissemination of the plan and thus is justified.
    • Tools: leaflets, posters, meetings.
    • Responsibility: the coalition, managers, supervisors; ultimately: everyone.
  • Empower others to act on the vision.

    • It requires providing tools and removing obstacles.
    • Involves communication with the stakeholders for ideas on implementation and complaints on obstacles.
    • Change cannot be carried out without empowerment. The step is justified.
    • Tools: a problem-reporting system; meetings, funding of the project.
    • Responsibility: the coalition (as decision-maker) and every stakeholder (reporting, suggesting, and implementing.
  • Plan for and create short-term wins.

    • Presupposes advertising noticeable improvements and rewarding successful workers.
    • Necessary for motivation and thus is justified.
    • Tools: data gathering; rewards (can be monetary).
    • Responsibility: the coalition.
  • Consolidate improvements and produce still more change.

    • Improvements are celebrated; problems are identified, reported, and eliminated.
    • Enables customization and sustainable improvement; thus, is justified.
    • Tools: a problem-reporting system; meetings, funding.
    • Responsibility: every stakeholder.
  • Solidify the change

    • Solidify the resulting practices as the hospitals policies.
    • Required for meaningful change. Justified.
    • Responsibility: coalition and management.

The Need for Change: Professional Collaboration

The first step establishes the need for change via professional communication and collaboration in data gathering, analysis, and dissemination.

Aligning the Model: Mission, Vision, and Values

  • Step three is specifically concerned with the hospitals mission, vision, and strategic goals.
  • Required to ensure the integrity of change and the appropriateness of outcomes.

Aligning the Model: Collaboration and Change Customization

  • The steps one and three are based on customization.
  • Steps four-seven involve further customization.

Applying the Model: Professional Collaboration of the Multidisciplinary Team

  • Communication and collaboration are required throughout the change.
  • Collaboration is needed between the disciplines: falls are affected by medications, environment, supervision, education, and training (Fitzpatrick et al., 2011).

Dissemination Strategy and Justification

  • Continuous dissemination of information is required for Kotters Model.
  • Dissemination is to be involved at different stages of the project, and the strategies can be multiple depending on the purpose.
  • For the final plan, awareness and understanding are to be raised with the help of meetings, discussions, and learning.
  • After the initial success, action research can be carried out, and an article about it can be published.

Proposed Budget

  • The plan requires minimum funding, but the majority of costs are unclear at the moment. The detailed budget is to be developed during stage three.
  • Posters and leaflets are likely to require funding. Internet research shows that it is possible to buy good-quality posters for $30 per unit; brochures can be purchased for $80. Depending on the quantity, store, and specifics of the order, the price can change.
  • Incentives. Depending on the efforts required of the coalition members, they can be working as volunteers or not.
  • Training. Depending on the training program chosen, funding may be needed.
  • Rewards. It can be monetary or not, token (for example, writing tools) or more significant and costly.
  • New equipment might be required for environmental improvement (Fitzpatrick et al., 2011). However, it is impossible to predict their costs at the moment.

Desired Outcomes

  • The desired outcome is a practically implemented model for a sustainable improvement of safety and quality in the field of falls in the elderly in hospital settings.
  • Key aspects: the practices of risk assessment, continuous improvement of the environment, and training and patient education training programs.

References

Boltz, M. (2012). Evidence-based geriatric nursing protocols for best practice. New York: Springer Publishing.

Cameron, E. & Green, M. (2015). Making sense of change management. London: Kogan Page.

CDC. (2016). Older Adult Falls. Web.

Fitzpatrick, M.A., Jorgensen, J., Forte, J., Kulik, C., Payson, C., Currier, A.,&Cardente, R. (2011). Special supplement to American Nurse Today  best practices for falls reduction: A practical guide. American Nurse Today, 6(3). Web.

King, C. & Gerard, S. (2013). Clinical nurse leader certification review. New York, N.Y.: Springer Publishing.

McDonnell, T. & Kerr, A. (2014). Interventions to prevent falls in an inpatient hospital setting. Age And Ageing, 43(1), 17. Web.

Sutherland, K. (2013). Applying Lewins change management theory to the implementation of bar-coded medication administration. Canadian Journal of Nursing Informatics, 8(1-2), 1-6. Web.

WHO. (2012). Falls. Web.

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