The relationship between patient falls and a home healthcare agency's (HHA) organizational culture is not easily measured. However, a combined home healthcare, palliative care, and hospice agency has successfully implemented a comprehensive educational program to help nurses and other clinicians decrease the number and severity of falls among patients. The program began with an organizational assessment and used an evidence-based approach to design a fall prevention and management program that fit the unique needs of our agency.
Best practices, accreditation, and national safety standards require that an organization respond to a fall when it occurs. A fall, like a medication error, can have serious consequences and even precipitate death. This program decreased the number and severity of falls among patients. This article describes our successful practices and recommends similar procedures to other agencies.
Most literature related to falls among home care patients addresses causes and contributing factors. The causes of falls are complex (Hendriks et al., 2008; Rubenstein, 2006). They include poor physical condition (Bright, 2005), medication mismanagement (Lewis et al., 2004), sensory impairment (Cumming et al., 2007; Grow et al., 2006), and depression (Sheeran et al., 2004).
However, the relationship between the organizational procedures of a given agency and the number and severity of falls among its patients has not been studied. Most agencies follow obvious organizational procedures, such as reporting the fall. However, the effectiveness of these procedures depends on how reporting is done and how much information is shared with the patient and family.
During the last 2 years, our home care agency has worked to reduce falls using evidence-based strategies as adapted from hourly rounding (performing hospital rounds every hour) (Meade et al., 2006; Melnyk, 2007). As we implemented our own program, our first objective was to look inward at the culture and operation of our agency. Meade's groundbreaking study showed that proactive nursing care, checking on patients before they used their call light to summon help, decreased negative outcomes such as falls and skin breakdown, increased satisfaction, and decreased the stress of nursing care. Many hospitals throughout the country have adopted this proactive approach to checking on patients each hour.
During these checks, nursing staff specifically asks patients about their pain levels, whether they need to go to the bathroom, and whether they have everything they need. Problems are prevented when patients have more contact with the staff.
In home care, nurses are not present continuously, so adaptations had to be made to the program. The primary caregivers were taught to do a modified version of hourly rounding. In homes we found that patients did not want to "bother" their caregivers. Wanting to minimize interruptions of others, patients fall reaching for a phone (as Zsa Zsa Gabor recently did at home). They also fall reaching for personal belongings, changing position when in pain, and going to and coming from the bathroom. Educating caregivers and patients to the need for routine monitoring in the home was done over a few months. This program is part of an overall agency initiative to decrease the incidence and severity of falls.
During our assessment, we found that the procedures involved in the collection, analysis, and reporting of falls within the agency could be improved. The coloring of forms notifying staff of quality assurance activity, the language of reporting falls, body language of supervisors, and other subtle characteristics of the agency were assessed. The 10 most significant characteristics that were discovered are summarized in Table 1.
Discussion of Findings
The most important characteristic of our agency is the willingness of all staff members to report falls of patients. Everyone has a responsibility to report falls. Emphasis on reporting falls is a key feature of the modified hourly rounding program for home care. These efforts began with the successful application of hourly rounding (Meade et al., 2006), which required home health clinicians to focus on the education and vigilance of family or community caregivers. Hourly rounding is a successful program in many acute care hospitals that has had a dramatic impact on patient satisfaction and outcomes (Meade et al., 2006). Translation was required for full implementation in home care and hospice.
Our goal is to maintain what Dekker (2007) calls a "just culture," meaning one that "protects people's honest mistakes from being seen as culpable." Our organization expects clinicians to report falls as a matter of professional responsibility. If a week goes by during which a specific clinician has not completed a fall report, the quality improvement coordinator will remind the clinician that every fall, major or minor, is important and even near misses must be reported if the agency is to address the problem of falls successfully. Because preventing falls, managing patient outcomes after they happen, and ensuring that the patient's injuries are handled effectively requires input and intervention from the entire team. In addition, the procedure for reporting falls is a simple process and occurs without any stigma attached. Clinical staff who do not report falls are asked about the incidence of falls in their patients. Staff who report high levels of falls are not considered to be "doing something wrong."
We believe every unreported fall is a missed opportunity to increase the agency's insight into falls. By extension, every reported fall is an opportunity to prevent a future fall. Based on our experience, the following suggestions for HHAs are presented:
1. Assume that clinicians want to help homebound patients achieve and maintain optimal health.
Clinical staff members are licensed and encouraged to become certified professionals. In addition to traditional clinical conferences, our agency holds ongoing labor management council meetings (Koloroutis, 2007) to solve problems and discuss operational and clinical concerns. The labor management collaboration benefits both the clinicians and the patients. We find the professional council is a force for innovation when clinicians, administrative, and management staff meet together.
2. Do not consider falls a normal part of illness or the end of life.
Clinicians should not expect falls to occur or regard them as normal. Instead, each fall should be viewed as indicating a problem with the patient's medical condition, home environment, family support, or other factor. Clinicians should promote patient-centered care by combining each patient's goal of optimal function with a genuine commitment to safety. Often, the patient and the caregiver need to negotiate goals. For example, our clinicians noticed that patients who have fewer falls are often patients with wounds. Educating the patient and family about the trade-offs between activity and rest helps the caregiver to focus simultaneously on the patient's needs and the patient's safety.
3. Work actively to break the code of silence through a team-focused approach.
Dekker (2007) refers to a "code of silence" among families and home healthcare staff, which can be a significant barrier to obtaining adequate information in an organization, in our case the incidence of falls throughout all services in the agency. The code of silence occurs when a patient does not want to bother the caregiver by requesting assistance or the family does not want to bother the clinician with a report of what they perceive as a minor fall. To break this code of silence, the clinician should continually reiterate to the family and patient that fall prevention is a part of care and that the HHA's goal is to help the patient stay at home and remain as active as possible. Normal fall management should not involve threats to notify adult protective services or vague suggestions that the patient may be institutionalized if he or she falls. Managing falls, like managing medication, requires patience, diligence, and optimism, along with a carefully crafted, individualized plan of care.
4. All clinicians should be involved in managing and preventing falls.
Managing falls is everyone's responsibility. Every guideline for preventing and reporting falls, including near misses, pertains to every person in the organization, not only patients and caregivers but also staff who answer the phone, clinicians who visit the patient, supervisors, and managers.
5. Clinicians report falls as a normal part of documentation.
Along with daily weight, vital signs, medication compliance, and progress toward goals, the clinicians report falls for all patients in the fall management program (Bucher et al., 2007). Reports include the number of falls and the severity of each specific fall, along with the follow-up care required. The clinician will modify the plan of care as necessary to address changes in the patient's condition (Rose, 2008). Modifications are made through the regular interdisciplinary team meetings and, as needed, given changes in condition.
6. Staffing patterns should reflect a commitment to preventing falls.
The case manager is responsible for assigning enough visits per episode to monitor a patient's status effectively, follow up on a fall, and allow time to comply with the agency's reporting and documentation procedures; the staff has the responsibility to act within the standard of care. Adequate staffing combined with a plan of care unique to the individual patient is essential to providing safe and effective care. For example, Vasquez (2009) recommends "front loading" visits to ensure adequate assessment and care planning from the start of care.
7. The fall management program focuses on continuous quality improvement.
Ongoing data collection related to falls is essential to an agency's effectiveness. Each person involved in the process should speak in nonjudgmental terms without singling out staff members whose patients have fallen (Yuan & Kelly, 2006). For example, the forms for reporting falls should be a common color, such as white or beige, as opposed to a bright color, which might cause anxiety or single out a clinician as someone who has apparently done something wrong. Staff members should regard a fall not as a failure to provide adequate care but as a concern to be addressed proactively by a multidisciplinary team as part of an ongoing plan of care.
8. The provisions of the fall management program should convey the agency's commitment to systems thinking.
The fall prevention program should integrate clinical, organizational, financial, and professional concerns. All staff members should be involved in collecting and analyzing data and in making recommendations for improvement in reducing the number and severity of falls. Because there are no simple falls, the fall prevention program should ensure that staff members comprehensively review each fall with regard to direct patient care, caregiver needs, staffing, care planning, and other related factors to prevent similar falls from occurring.
9. The fall management program should address each family's needs holistically.
Patients and caregivers, especially those who do not want to bother the clinician by reporting falls, should be cared for holistically. Patients and caregivers should understand that home care staff must report adults who seem unable to care for themselves in their homes to adult protective services. Incorporating the patient's self-image into the discussion has been helpful in planning patient-centered care.
At every visit, clinicians should ask patients whether they have fallen. Patients or caregivers may not remember every fall, especially if they view falls as a normal part of the patient's disease or condition. When falls occur, clinicians should ask probing questions, "peeling back the layers of an onion," to uncover subtle changes in the patient's condition (Moylan & Binder, 2007). When a patient is dressed when the clinician arrives, if the patient reports a fall, the clinician examines the affected area followed by an in-depth patient interview and postfall assessment. In addition, the clinician should directly observe the patient's ability to perform activities related to daily living, especially activities likely to lead to a fall, such as visits to healthcare providers. The home care plan should consider the means of getting the patient to and from the car for office visits and other therapies.
10. The agency should analyze falls at the patient level, the agency level, and the corporate level.
Staff members should discuss the effectiveness of each patient's fall management program at each interdisciplinary group meeting. At quarterly meetings, home healthcare offices within the service area should share effective programs and work together to promote each patient's safety and well-being. Our healthcare agency is working to educate the larger healthcare community about fall management and prevention through web resources and an increased emphasis on research (Pastor, 2009; Smith-Stoner, 2004a, 2004b) and evidence-based practice.
The initial evaluation of the agency's fall prevention program revealed a dramatic drop in the number of moderate-level falls (Table 2). Some reporting of falls was expected to increase as everyone became aware of the need for more comprehensive reporting. Further research is in progress to analyze the types of falls and determine which of the Four P's (pain, position, potty, and personal items) is most commonly associated with falls.
The organization hopes to present a more detailed description of this fall prevention program in future publications. We are participating in a nurse/scientist partnership between the healthcare system and local universities to assist in evaluating and reporting on the fall management program and plan to have the formal evaluation completed in Winter 2010.
Preventing and managing falls requires an ongoing reinvestment of agency resources to provide quality care for patients at greatest risk for fall (Taft et al., 2005; Wong et al., 2008). The challenge for this agency and others dedicated to preventing falls will be to maintain a focus on systematic reporting and creative approaches to updating the fall management program as necessary.
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