Secondary Logo

Journal Logo

Department: Quality Improvement Matters

Gap analysis

A tool for staff engagement in fall reduction improvement processes

Lamb, Karen V. DNP, RN; Ambutas, Shirley A. DNP, APRN, CCRN-K, CCNS; Sermersheim, Emily R. DNP, MPH, RN-BC; and; Ellsworth, Mary J. MSN, RN-BC

Author Information
Nursing Management (Springhouse): October 2020 - Volume 51 - Issue 10 - p 16-22
doi: 10.1097/01.NUMA.0000698108.86942.f9
  • Free

Falls are the most frequent safety event observed in hospitals.1 According to the Centers for Medicare and Medicaid Services, falls with injury qualify as a hospital-acquired condition because they're considered to be preventable events and, therefore, not reimbursable.2 Fall rates in acute care settings range from 1.3 to 8.9 falls per 1,000 patient days, and rates are even higher on units that provide special care, such as geriatrics, neurology, and rehabilitation.3 An analysis of patient falls at academic medical centers revealed fall rates ranging from 2.90 to 3.31 falls per 1,000 patient days, with an estimated 30% to 50% of falls resulting in injuries.4

Not only do fall-related injuries impact patients' quality of life, they're also extremely costly for organizations. Injurious falls result in increased length of stay related to associated comorbidities and mortality and cost an average of $13,806 per hospitalization.5,6 Given the scope and complexity of this problem, as well as the reimbursement factor, there's a continued search to find best practices to provide safe patient care in the areas of fall reduction and injury prevention.

This article describes how gap analysis was used to engage staff in a quality improvement (QI) project that aimed to decrease fall rates. The initiative resulted in a 60% reduction in falls over 7 years.

The RUSH Way methodology

Our tertiary care academic medical center experienced fall rates that exceeded National Database of Nursing Quality Indicators® (NDNQI®) benchmarks by more than 40% on two units. The hospital's fall oversight committee, a department-level committee cochaired by a clinical nurse specialist with expertise in fall prevention and a nursing professional development specialist from the centralized education and quality department, was charged with facilitating a fall reduction program to reduce the risk of patient harm.

The fall oversight committee addressed the problem by using the organizational QI methodology called the RUSH Way. Developed by Rush University Medical Center, the RUSH Way focuses on improving current trends by implementing an updated, evidence-based fall reduction and injury prevention program to decrease fall rates. RUSH stands for ready, understand, solve, and hold, and uses tools from existing quality methodologies such as PDCA (Plan, Do, Check, Act), Lean, and Six Sigma.

During the ready phase, frontline nursing staff members identified the problem from their perspective. At this initial stage, the complexity of the problem and the need to involve other members of the interprofessional team were discovered. Frontline nursing staff and other team members were then engaged to drive the fall reduction process and ensure sustainability. Additional stakeholders, including pharmacy, risk management, and purchasing, were identified and invited to join the fall oversight committee.

In the understand phase, the fall oversight committee reviewed the existing process and the related fall rate metrics, which included a unit-based gap analysis. The solve phase focused on removing the obstacles that were contributing to performance issues. And the hold phase focused on sustaining the improved performance or holding the gains. Institutional Review Board approval wasn't sought because the project was a QI study.

Conducting the gap analysis

Successful implementation of a fall reduction program is a complicated process that involves the use of a wide variety of strategies.1,2,4 In the understand phase, it's important to assess current practices and the extent of supportive structures and processes in place. The Agency for Healthcare Research and Quality (AHRQ) recommends conducting a gap analysis as an initial step in implementing a successful fall reduction programs.7 The gap analysis process includes a full review of both gaps and strengths in best practices, comparing actual performance with expected and ideal performance, which is crucial for engaging nursing staff in the improvement process to identify deficits and address problems through corrective actions.

A process improvement leader on the project developed our gap analysis tool and individualized it to the organization based on best practices supported in the literature, including the AHRQ's Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care and the Department of Veterans Affairs falls toolkit.7,8 The AHRQ recommends designing the gap analysis to determine best practices currently in place, deviations from best practices and organizational policy, and organizational and unit differences.7

During the understand phase, the gap analysis was conducted at the unit level on two pilot units with fall rates that exceeded benchmarks. The purpose of the gap analysis was to understand the current state of practice for fall reduction and injury prevention compared with best practices outlined in the literature and current organizational policies and procedures. Because no one practice prevents falls or injuries, the gap analysis included a review of practices related to communication of patients identified as being at risk for falls, the establishment of individualized care planning, structural processes such as a unit fall team, audits of correct implementation of fall standards, completion of postfall huddles, and availability and use of equipment such as floor mats.1,9 (See Table 1.)

Table 1:
Table 1::
Selected gap analysis categories7

Frontline nursing staff on the two pilot units initially completed the unit-based gap analysis, submitting results in an electronic format to the process improvement leader. This activity helped engage staff members in the QI process and empowered them to identify opportunities for improvement based on their findings. Through identified gaps, individualized unit action plans were developed. The pilot units' representatives presented the findings at fall oversight committee meetings, along with specific unit corrective action plans, so all units could benefit from lessons learned during the improvement process.

Gaps identified on the pilot units included lack of interprofessional team involvement, especially therapy and pharmacy services; missed rounding opportunities; inconsistent use and documentation of the teach-back process; a deficiency in conducting postfall huddles; and a lack of readily available fall prevention equipment. Based on these findings, unit-specific improvement plans were developed, as well as a focus on improving structures and processes to decrease falls and related injuries throughout the organization.

Interprofessional team involvement

Results from the gap analysis identified the need for active involvement of other disciplines on unit fall prevention committees in addition to nursing. This was also supported in the literature.10-12 Based on these findings, physical therapists, occupational therapists, pharmacists, and hospitalists were invited to join the unit teams. These teams focused on reviewing fall quality data and postfall huddle reports as a method of monitoring trends and making recommendations for unit-specific improvements based on the trends identified.

During the pilot, improvement teams were led by frontline nursing staff champions at the unit level and supported by unit directors who play a pivotal role in creating environments that support best practices and a culture of safety. These unit-based teams reported to the fall oversight committee, which reports to the nursing quality improvement committee and collaborates with the executive sponsor, an assistant vice president who reports to the CNO.

Structured rounding

Structured rounding to improve toileting was identified as an area for improvement during the gap analysis. In previous studies, structured rounding was associated with decreased fall rates.13,14 The purpose of structured rounding is to determine the patient's needs, including toileting, and meet him or her proactively rather than reactively.9 Staff perception of structured rounding wasn't always consistent with the intent of this process. Some staff members considered structured rounding to be completed when they were in patient rooms providing direct care, but they didn't focus purposefully on the patient's needs and providing him or her with information about the purpose of rounding.

In an effort to change this perception, brief educational sessions were held on providing toileting assistance, addressing comfort needs such as pain and positioning, placing equipment in reach, and reassurance of the nurse's presence.13 To help facilitate staff accountability for this process, unit leadership team members rounded daily on patients to evaluate critical factors in fall prevention, such as the environment, communicating to the team that a patient was at risk for falling, and the overall patient experience. These rounds helped determine if patient needs were met, and the unit directors communicated this feedback to frontline nursing staff members so they could make improvements based on specific findings.

Patient and family education

A best practice for patient and family education, the teach-back process involves both education and evaluation of the learning as a critical tool for fall reduction and injury prevention.15 Based on data from documentation audits during the gap analysis, it was found that the teach-back process was neither consistently carried out nor documented on the units. A computerized staff education module on the teach-back process was developed and added to annual staff competencies. In addition, the electronic medical record was modified to include documentation of the teach-back process.

Postfall huddles

The gap analysis identified a deficit in conducting postfall huddles after every fall as outlined in the hospital's policies. As such, a standardized tool for postfall huddles was developed and implemented. The tool includes an analysis of the “who, what, when, where, why, and how” of a fall event. The huddle tool was also used to determine if falls were preventable and identify interventions needed to be put in place to prevent repeat falls. Interprofessional staff members were involved in postfall huddles as a strategy to determine opportunities for improvement at the unit level and garner staff buy-in for improving patient safety.

The unit-based clinical nurse specialists championed the postfall huddles, promoted communication among team members, and coached frontline nursing staff. At the monthly unit-based fall committee meeting, postfall huddle trends were discussed and identified. Information from the huddles was shared with staff and used to revise individualized patient interventions, as well as improve system and process issues. For example, from the huddles we noted that staff members weren't using floor mats when appropriate for patients at risk for falls with injury.

Use and availability of equipment

Through the gap analysis, it was noted that the pilot units didn't have a complete inventory of equipment for fall prevention and injury reduction, such as gait belts, walkers, bedside commodes, and floor mats. There were incidents where lack of appropriate equipment was a contributing factor in fall events. Processes were put into place to make equipment more readily available and the fall oversight committee recommended augmenting fall prevention equipment for all units.

The process of working with the purchasing manager (a nurse) for ordering specific equipment was communicated to unit leadership. Because none of the purchases met the threshold for capital expenditures, there were no budgetary issues in purchasing the equipment. Additionally, physical therapy partners provided staff education on the use of transfer and mobility equipment, and unit-based fall teams championed and modeled correct use of fall prevention equipment.

Existing strengths

Completion of the gap analysis also identified strengths in structures and processes. One strength is the organization's commitment to a culture of safety. There's a focus on safe patient handling supported with readily available lift equipment at the unit level for mobilizing patients. Another strength is the process used to monitor progress in achieving benchmarks. At monthly fall oversight committee meetings, the NDNQI fall data are reviewed with a focus on identifying trends and planning related improvements to meet organizational benchmarks for fall and falls with injury rates.

Staff adherence with fall safety event reporting is another strength. Fall safety events are reported through an electronic mechanism, which includes fall definitions. Identifying the type of falls, such as accidental, anticipated physiologic, or unanticipated physiologic, is important information to track trends and determine whether individualized interventions have been implemented.16

Holding the gains

After the fall reduction program was implemented on the pilot units, unit fall champions audited program components via documentation and patient observation to determine adherence to revised policies and practices. In addition, the important outcomes of fall and falls with injury rates were tracked. Data from the audits provided the pilot units with continuous, specific feedback on accomplishments and areas for improvement. This feedback, with the focus on identifying potential problems in daily workflow, fits into the hold phase of the RUSH Way's methodology and is a hallmark of highly reliable healthcare organizations.17

The analysis of audit data and fall trends by unit champions was another method that kept staff engaged in the process. The champions and frontline nursing staff members felt empowered to use findings from the gap analysis and audits to make changes at the unit level. For example, one unit identified that their patients experienced frequent falls during shift changes. As a result, the unit implemented procedures for unlicensed assistive personnel to increase vigilance in answering call lights during this vulnerable time.

Ensuring data transparency is a critical factor in holding the gains. The pilot units posted reports outlining trends of fall data in highly visible locations to update staff on the program's progress. Results of each unit's fall and falls with injury rates were reviewed at both unit fall committee meetings and fall oversight committee meetings. After a patient fall, frontline nursing staff members assisted with postfall huddle form completion, case reviews, and dissemination of pertinent information through the organization's quality structure. Recognition of efforts to reduce falls, such as gift cards, fall prevention pins, and WOW awards (given to staff for exemplary performance), was incorporated into the program to promote accountability and sustainability.

We've seen a steady decrease in falls since the project began on the pilot units, as well as the entire organization once successful elements of the program observed on the pilot units were implemented on all units. (See Figures 1 and 2.)

Figure 1:
Figure 1::
Falls per 1,000 patient days on the pilot units
Figure 2:
Figure 2::
Falls per 1,000 patient days on all inpatient units

Achieving success

The gap analysis process was a starting point for a successful QI project that resulted in decreased patient falls. Although the literature supports the gap analysis, we were unable to find sources that outline the use of this tool in planning and implementing successful fall reduction programs.7 Our use of the gap analysis combined with the RUSH Way methodology allowed us to identify areas for improvement in structures and processes for fall reduction. We then used these findings to implement our improvement plan. In addition, we found that through a collaborative approach with frontline nursing staff, therapy services, and pharmacy and support services, unit leadership developed action plans to address opportunities for improvement.

Since this program used one specific QI method, it will be important to use gap analysis with other QI methodologies in other organizations to determine if the same results can be achieved. Gap analysis completion needs to be repeated periodically if falls or fall-related injuries increase, after organizational changes, or as new evidence supports changes in practice.

The important implication from this project is that QI processes and tools such as the gap analysis are methods that can be used to successfully gain staff engagement in programs to reduce patient falls and improve the organization's culture of safety. When all interprofessional team members own the issue of falls, a culture of safety develops.7

The positive results of this project highlight the importance of conducting a gap analysis before implementing specific improvement processes. The gap analysis process can easily be used in other organizations that want to focus on improving fall rates.


1. Rowan L, Veenema TG. Decreasing falls in acute care medical patients: an integrative review. J Nurs Care Qual. 2017;32(4):340–347.
2. Centers for Medicare and Medicaid Services. Hospital-acquired conditions. 2020.
3. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645–692.
4. Williams T, Szekendi M, Thomas S. An analysis of patient falls and fall prevention programs across academic medical centers. J Nurs Care Qual. 2014;29(1):19–29.
5. The Joint Commission. Sentinel event alert: preventing falls and fall related injuries in health care facilities. 2015.
6. Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37(2):81–87.
7. Ganz DA, Huang C, Saliba D, et al. Preventing falls in hospitals: a toolkit for improving quality of care. Agency for Healthcare Research and Quality. 2013.
8. US Department of Veterans Affairs. VA National Center for Patient Safety. Falls toolkit. 2014.
9. Ambutas S, Lamb K, Quigley P. Fall reduction and injury prevention toolkit: implementation on two medical-surgical units. Medsurg Nurs. 2017;26(3):175–179.
10. Graham BC. Examining evidence-based interventions to prevent inpatient falls. Medsurg Nurs. 2012;21(5):267–270.
11. Godlock G, Christiansen M, Feider L. Implementation of an evidence-based patient safety team to prevent falls in inpatient medical units. Medsurg Nurs. 2016;25(1):17–23.
12. Volz TM, Swaim TJ. Partnering to prevent falls: using a multimodal multidisciplinary team. J Nurs Adm. 2013;43(6):336–341.
13. Tucker SJ, Bieber PL, Attlesey-Pries JM, Olson ME, Dierkhising RA. Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews Evid Based Nurs. 2012;9(1):18–29.
14. Woodard JL. Effects of rounding on patient satisfaction and patient safety on a medical-surgical unit. Clin Nurs Spec. 2009;23(4):200–206.
15. Agency for Healthcare Research and Quality. Health literacy universal precautions toolkit, 2nd edition. Use the teach-back method: tool #5. 2020.
16. National Database of Nursing Quality Indicators. Press Ganey Associates, Inc.; 2018.
17. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459–490.
Wolters Kluwer Health, Inc. All rights reserved.