Balancing the complexity of patient falls: implementing quality improvement and human factors/ergonomics and systems engineering strategies in healthcare

Introduction: Falls are the leading cause of death due to injury among the elderly. Every 24 minutes an older adult dies from a fall related injury. Studies using 3 different methods were performed at a large urban, academic medical center in the US. Aim #1: Understand the advantages and disadvantages of QI methodologies (Lean and Six Sigma) and HFE when applied to fall prevention in the acute care setting: o Evaluate the contribution of QI and HFE to fall prevention with a focus on reducing falls with serious injury. o Use studies with different methodologies (Lean, Six Sigma) to develop and implement an intervention with the goal of decreasing total falls and falls with injury. o Compare methodologies (Lean, Six Sigma and HFE) to understand their benefits and limitations. Aim #2: Develop recommendations for fall prevention: o Investigate interventions and assess success of fall prevention. o Develop an understanding of interventions that prevent falls resulting in injury. Methodology and Results: Study #1 (Method = Lean, Intervention = Standard Work): Study #1 used Lean techniques such as standard work to improve fall risk assessment and intervention selection. Total falls decreased by 22%. At first glance this appears successful but a deeper evaluation of the serious injuries revealed more improvement is needed. There were still 15 falls with serious injuries that occurred among the three oncology divisions. These rare but serious injuries result in a longer hospital stay and increased cost of treatment that is not reimbursed. Due to a climate of increasing financial pressure further reduction of serious injury was desired. Study #2 (Method = Six Sigma, Intervention = Patient Partnering: Study #2 used Six Sigma tools to investigate root causes of falls. An intervention called Patient Partnering was developed to encourage patients to call for help and participate in preventing their own falls. There were no falls with serious injury for over 14 consecutive months. However, the intervention was difficult to sustain due to resistance from nurses and patients. Falls with injuries resumed as the intervention ceased. Study #3 (Method = Qualitative HFE, Intervention = Patient Interview): Study #3 was a qualitative study based on Human Factors principles to understand patient s perception of fall risk. It was found that patients did not think they would fall and felt particularly safe and protected while in hospital. They found it difficult to get around with IV tubes and crowed spaces. They wanted information and assistance when they need it, in the format they prefer (customized for each individual patient). Impact on society: Falls prevention interventions need to be designed for all the stakeholders (patients and staff). Patients think nurses will keep them safe and are willing to participate with fall prevention if they feel it is tailored to their needs. Until all perspectives are taken into account it is unlikely that there will be sustained and embedded improvements. Key message: Falls with injury are rare events with complex root causes that require agile solutions with constant revision to align with rapidly changing conditions and interactions. Reducing injury will take a balance between safe environment, organization, processes, tasks and behaviors from staff and patients