Running head: PREVENTING FALLS

Quality Improvement Process for Preventing Patient Falls

Ashleigh Windel
Ferris State University

PREVENTING FALLS

Quality Improvement Process for Preventing Patient Falls

A new policy called the no pass zone, will be put into effect in order to prevent patient
falls while promoting patient safety and reducing the hospital costs associated with patient falls.
According to Tzeng & Yin (2009), research shows that there are several contributing factors to
patient fall rates that include; call light response time, room set-up and human resources.
Implementing a no pass zone policy will help reduce contributing factors and lower patient fall
rates.
Transformational leadership will be used as a guide for executing the new policy within
this healthcare institution. Yoder-Wise (2015), states that transformational leadership is a
relationship between leaders and followers where they can come together to solve a problem and
manage change. This type of leadership is ideal for implementing change in healthcare. There are
5 key practices: questioning how things have been done to create a new solution, inspiring a
shared vision between leaders and followers; empowering people to act, modeling the change
and encouraging others to change (Yoder-Wise, 2015).
Identified Clinical Needs
The old Spectrum Health policy on call light response time did not include any details
prohibiting staff from walking past an unanswered call light. The new policy to be implemented
prohibits healthcare staff members from passing a call light without answering it. According to
Spetz et al. (2015), falls occur in 2% to 20% of inpatient hospital stays and 10% to 30% result in
injury. Falls that occur in the hospital result in a lack of reimbursement for patient care because
they are considered a hospital-acquired condition (Spetz et al., 2015). The healthcare institution
where the fall occurred has to pay for examinations following a fall and treatment of any injury

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sustained. In the study conducted by Spetz et al. (2015), costs of non-injurious patient falls
ranged from $1,139 to $2,033 and costs of injurious patient falls ranged from $7,136 to $15,444.
Furthermore, costs of serious injurious patient falls ranged from $17,567 to $30,931 (Spetz et al.,
2015). Patient falls can even lead to lawsuits which further drives up the hospitals costs.
Implementing this new policy will not only save the hospital money but it will uphold a
reputation of quality healthcare being provided. Part of the Spectrum Health mission states that
patients deserve the highest quality of safe care through a holistic approach, sensitive ongoing
assessment and responsive service delivery (Spectrum Health Care, 2015). Executing a no pass
zone will come at little to no cost while reflecting upon the Spectrum Health mission, vision
and values. This change in policy will increase patient safety and reduce hospital costs for
inpatient falls.
Interdisciplinary Team
The direct interdisciplinary team is comprised of nurses, nurse techs, physicians,
social workers, case managers, and physical therapists that must work together to achieve costeffective care while achieving a high quality of care (Yoder-Wise, 2015). These members of the
healthcare team are responsible for providing direct quality safe care while individually working
with the patient. These individuals work directly with patients and will be responsible for
carrying out the new policy. The indirect interdisciplinary team is comprised of stakeholders, the
finance department and administration. The stakeholders will ultimately decide on whether a
new policy is in the best interest of their organization and if it should be implemented. Finance
will determine what effect the new policy will have on the budget. Administration will ensure
that the new policy meets standards set by Joint Commission and that is being enforced
throughout the hospital.

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Collection Method
Data collection is carried out by those wishing to implement a new policy. This process
starts with researching evidence based practice supporting the new policy. Articles of evidence
based practice will be analyzed for limitations, bias and results. Once enough support is gathered
to execute the new policy a trial run should be initiated. One unit of the hospital may be selected
to implement the new policy first to see how it plays out. Inpatient falls and call light response
time data will be compared before and after implementation of the policy to determine
effectiveness. If the new policy has support from evidence based practice research, proves to be
effective in reducing the number of inpatient falls and reduces hospital costs then it can be
implemented hospital wide.
Outcomes
An outcome of implementing the no pass zone policy is improvement on 5 of the
professional standards of nursing practice. Standard 5 implementation, states that the
registered nurse will carry out the identified plan for the patient (ANA, 2010). Quality care and
patient safety are a part of every patient care plan. By following a no pass zone policy these
integral parts of patient care will be upheld. Standard 7 ethics, states that the registered nurse
delivers care in a manner that preserves and protects patient autonomy, dignity, rights, values
and beliefs (ANA, 2010). Similar to standard 5, this standard will be improved on because this
new policy is designed to improve protection of the patient. Standard 8 education states that
the registered nurse seeks experiences that reflect current practice to maintain knowledge, skills,
abilities, and judgment in clinical practice or role performance (ANA, 2010). Initiating the no
pass zone is an experience of current practice that can provide an educational opportunity for
nurses to review the evidence based practice that supports it. Similar to standard 8, standard 9

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evidence-based practice and research, states that the registered nurse will use current evidence
based nursing knowledge to guide practice (ANA, 2010). Standard 10 quality of practice,
states that the registered nurse will participate in quality improvement. The new policy is a
measure of quality improvement aimed to reduce the number of patient falls and improve patient
safety.
Implementation Strategies
Kurt Lewins theory of change called Force Field Analysis Model will be used to execute
this new change in policy (Bozak, 2003). According to Lewin, unless individuals perceive a need
for the change then the driving force will be negative and therefore limit success (Yoder-Wise,
2015). The force field analysis is a strategy that encourages adaptation to change through goal
planning, good communication skills, involvement of the individuals affected by the change and
support of management (Bozak, 2003).The first step in implementing the no pass zone policy
is called the unfreeze step and it involves making the direct interdisciplinary team (nurses, nurse
techs, physicians, case managers, social workers and physical therapy) aware of the need for
change and helping them get ready to change (Yoder-Wise, 2015).
In order to make members of the team aware, administration will present the new policy
to unit and department managers. The presentation will include education on the policy, evidence
based practice supporting it and a reminder of the high quality of care that the institution is
entitled to uphold. Mangers can take this information and hold meetings on their floor. For
example, the nurse manager of a unit will require all nurses and nurse techs to attend one of the
unit meetings so they can receive information of the policy change. Incentives (recognition of
adhering to the new policy and unit events like planned pizza parties) will be provided to
encourage staff to be facilitators of change and have positive approaches. According to Bozaks

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article on the Lewin theory, the driving forces, the direct health care team, must be strengthened
in favor of the change while the restraining forces are eliminated (2003).
Next comes the changing stage (Bozak, 2003). The new policy is posted in areas where it
can be viewed as a reminder to staff. A date is set to begin implementing the new policy on the
unit and all staff will be expected to adhere to it. Along with positive incentives there will
negative incentives to increase compliance with this change. Employees not following the policy
or presenting a nonconstructive negative attitude towards the change will receive a warning from
managers. Failure to make a change will result in remediation with administration with one last
opportunity for change before termination.
Lastly is the refreezing step where change is stabilized throughout the organization
(Bozak, 2003). Measures to ensure that the no pass zone policy will remain in effect are
continued. Evaluations of staff are completed by the managers to ensure that they are following
all policies and protocols. According to Yoder-Wise (2015), nurse managers will measure the
impact of changes, ensure that changed behaviors continue, provide staff with progress reports
and evidence of success.
Evaluation
The effectiveness of the no pass zone policy on the patient fall rate and hospital
expenses will evaluated by the finance department and administration on a monthly basis from
unit to unit. The goal of the new policy is to reduce patient fall rates, improve patient safety and
reduce hospital expenses related to falls. The monthly evaluations will include management
tracking patient falls on each unit. Each month the new rate will be compared with previous
months to determine if the policy is effective. In addition, managers will also keep track of the

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reasons for falls to determine effectiveness and if there are any other prevalent contributing
factors. The hospital finance department will compare hospital costs related to inpatient falls
monthly from unit to unit to determine if the policy has been effective in reducing costs.
Conclusion
Research shows that a no pass zone policy is one way to reduce the number of patient
falls and reduce hospital costs. It is an evidence based practice that should be implemented in
hospitals. Use of Force Field Analysis strategy for change can make implementing this policy
smoother. Spectrum Healths mission includes providing high quality safe care to patients
(Spectrum, 2015). Through transformational leadership employees can share the vision of the
organization and help drive it forward (Yoder-Wise, 2015). By requiring employees to answer a
call light instead of walking past it the institutions mission will be upheld and patients will be
receiving the high quality safe care that is promised.

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References

American Nurses Association (2nd ed.). (2010). Nursing: Scope and standards of practice. Silver
City, MD: Nursebooks.org
Bozak, M. (2003). Using lewin's force field analysis in implementing a nursing information
system. Computers, Informatics, Nursing, 21(2), 80-85. Retrieved from
http://journals.lww.com/cinjournal/Fulltext/2003/03000/Using_Lewin_s_Force_Field_An
alysis_in_Implementing.8.aspx
Mission/vision/values (2015). In Spectrum Health Care. Retrieved July 27, 2015, from
http://spectrumhealthcare.com/mission-vision-values
Spetz, J., Brown, D., & Aydin, C. (2015). The economics of preventing hopsital falls:
Demonstrating ROI through a simple model. The Journal of Nursing Administration,
45(1), 50-57. doi:10.1097/NNA.0000000000000154
Tzeng, H. M., & Yin, C. Y. (2009). Are call light use and response time correlated with inpatient
falls and inpatient dissatisfaction? Journal of Nursing Care Quality, 24(3), 232-242.
doi:10.1097/NCQ.0b013e3181955f30
Yoder-Wise, . Leading and managing in nursing. 6th ed. St. Louis: Elsevier, 2015. Print

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