Safety, Quality, and Informatics

Running head: SAFETY SCORE IMPROVEMENT PLAN 1

SAFETY SCORE IMPROVEMENT PLAN 9

Safety Score Improvement Plan for Newark Beth Israel

Samantha M. Tallarine

Capella University

Organizational and Systems Management for Quality Outcomes

Safety Score Improvement Plan

July, 2018

Safety Score Improvement Plan for Newark Beth Israel

Newark Beth Israel Medical Center is the largest hospital in Newark, New Jersey. They have 480 total staffed beds, and are at the forefront of medicine when it comes to heart, as well as lung transplantation. Although they have a B rating according to the Hospital Safety Score Web Site, they do have some areas to improve upon; an example of this is patient falls. Their score of 0.541 is just below the average (0.371) however, still unacceptable.

The drop in average of patient falls negatively impacts the image of the hospital, which can lead to decrease in patients, and a drop in funding. Although Newark Beth Israel is functioning at an above average level, there is always room for improvement. Improving upon the fall protocol on each unit, and educating nurses, doctors, and other members of the interdisciplinary team, we can all work together to make patient falls a thing of the past.

Contributing Factors to Patient Falls

“According to the Agency for Healthcare Research and Quality, more than 1 million patient falls occur each year in the United States.” (Murphy, Murphy, Hastings, & Olberding, 2015) Falls are something that have become common in the healthcare field, but can often become deadly to a patient; “10% result in serious injuries such as fractures or head trauma.” (Murphy, Murphy, Hastings, & Olberding, 2015) What isn’t discussed about patient falls is that they also lead to an increased stay for patients, making them more susceptible to infections that they may have never come across if they were being cared for at home. Also, if a patient falls while in the care of the healthcare professionals in the hospital, Medicare and Medicaid do not reimburse the hospital for costs associated with that injury. Therefore, the higher fall rate during hospitalizations, the more of a loss the hospital is working at.

Stubbs, and Sikes explored falls on inpatient pediatric units, and were able to pinpoint some factors that were found to increase the likelihood of falls. “Increased length of stay, need for antiepileptic medication, seizure disorders, physical therapy or occupational therapy assistance, and musculoskeletal conditions. Other studies have shown that pediatric inpatients at greatest risk for falls are either less than 3 years old or an adolescent with a neurological diagnosis.” (Stubbs & Sikes, 2017) Adult patients also face similar risks when faced with these conditions, and increasing age is the most prevalent.

Protocols currently in place in hospitals are also questionable, and many nurses believe that there is not enough being done to inform members of the healthcare team of a patient’s risk level. Another issue is that units aren’t staffed efficiently enough to monitor the patients throughout their hospital stay. Family members can be incorporated into the care plan, but the level of their competency needs to be measured before any responsibility is placed upon them. This would require more counseling, as well as more staff for evaluation and implementation. Falls cannot be reduced and eventually eradicated within the hospital until all members of the interdisciplinary team are on the same page and willing to work together.

Nurse Leaderships Role in Fall Prevention

The upper management within the nursing department needs to dedicate themselves to staying on top of their current employees to be monitoring patients at all times. They need to make sure that they are following protocols in place, as well as being open to listen to any suggestions that may be made. Nursing leaders need to offer an open platform for all employees, and be willing to implement changes that are needed to suit the needs of both the staff and the patients. Also, future employees should go through a rigorous orientation period, which equips them with the tools they need to assess for the risk of falls occurring, as well as being trained to step in at any moment that a fall does occur.

Policies and Procedures

Within the Newark Beth Israel Medical Center, policies and procedures need to be amended to ensure patient safety. Upon researching what they are doing to reduce their number of falls, I came across a serious lack of policy regarding the matter. It seems they are more concerned of any legal action that would be taken against them after the fact, rather than trying to eliminate the risk in the first place. Nursing leadership, as well as the floor nurses need to take matters into their own hands and start the process to implement a new policy to help protect their patients, which helps the nurses in the long run. Patient falls are considered “a nurse sensitive measure and nurses play a key role in this component of care.” (Quigley & White, 2013) That being said, nurses have everything to gain by implementing changes within their units to help patients get optimal care, as well as protecting their own license.

Systems Theory

“Complex adaptive system theory, and outgrowth of complexity theory, suggests that the relationship between elements or agents within any system is nonlinear and that these elements are the key players in changing settings or outcomes.” (Marquis & Huston, 2017) This means that if an individual acts one way, they may not act the same way the next time they’re faced with the same scenario. As humans, we learn from our mistakes as well as our triumphs; nobody knows how they will react in a certain situation, until faced with it. This is relevant to the issue with patient falls because it theorizes that if a nurse is properly trained and goes through a rigorous orientation and possible simulations, they will be better equipped to handle all aspects of their jobs, particularly falls.

That being said, if nurses start implementing new policies within this organization we will have policies and procedures that come from first-hand experience. Nurses are taught to always advocate for their patients, and this opportunity allows them to do that for all their patients at once, both current and future. Having seasoned nurses bring their experiences one by one to the nursing leadership will ensure that we will have new policies that fit the needs of both the patients and the nurses. Although nurses receive majority of the blame for when a patient experiences a fall, some patients are prone to falls regardless of receiving excellent care. Having a policy that which protects the nurse from being wrongfully accused, as well as one that protects patients from any negligence is the ultimate goal.

Recommendations for Safety

Through my research, I’ve come across many different suggestions to reduce the growing number of falls reported during hospitalizations. There are a number of different ideas that all could work if implemented correctly. A system also needs to be put in place to monitor the effectiveness of these strategies. Nursing leadership working hand in hand with their subordinates, as well as the rest of the interdisciplinary teams can lead to greater patient safety which in turn will lead to higher reviews for the hospital, and will allow for full reimbursement for stays from Medicare and Medicaid.

6-Pack Prevention Plan

One proposed solution is to have a prevention program in place that “includes a fall-risk tool; ‘falls alert’ signs; supervision of patients in the bathroom; ensuring patients’ walking aid are within reach; toileting regimens; low-low beds; and bed/chair alarms.” (Barker, Morello, Ayton, Hill, Brand, Livingston & Botti, 2017) The study received positive reviews amongst the nursing staff, and with proper implementation can be extremely productive. If this were to be put into place, there would need to be proper training sessions before implementation. Nurses should be paired up in order to help each other properly survey their patients, and assess their risk level. Pairing up nurses, preferably a seasoned nurse with a new nurse, allows the proper amount of surveillance, and will provide extra hands on deck to care for patients effectively.

In order to measure the effectiveness of this program, data would need to be conducted of what the fall percentage is prior to implementation, as well as the fall rate at least one year after implementing it. Also important, is to make sure your staff is happy as well. Surveys would need to be conducted of the employees, as well as patients and their families to monitor how the new protocols are being perceived.

Roundtable Debriefings

In 2012, a Falls Roundtable intervention was brought into discussion to be implemented in the emergency department in an urban hospital. The whole point of this was to allow for debriefing when an incident occurs to achieve fall-reduction rates. This leads to actually confronting the issue, and speaking about what happened, as well as figuring out a way to prevent future incidents. It is a meeting held weekly and includes “1 nursing quality outcomes coordinator, 2 acute care clinical nurse specialists, the director of acute care nursing services, 1 physical therapist, 1 education and development nurse, and 1 pharmacy resident.” (Murphy, Murphy, Hastings, & Olberding, 2015) The nurse who was caring for the patient at the time of the fall was always part of the debriefing as well, in order to get the complete picture of what occurred and could lead to a better overall outcome.

This plan only works in conjunction with other fall precautions; alone, it was not found to consistently keep fall rates decreased. It did however, lead to the staff becoming more engaged in implementing new fall-prevention measures, and being more focused on their individual patient outcomes. Nurse leadership can use this as one of the tools to reduce falls, and boost morale among the staff. Instead of automatically penalizing nurses for their patients experiencing a fall, it allows them a safe space to explain what happened, and different perspectives among healthcare professionals to come up with new and ever changing protocols.

Red Light, Green Light

This proposed solution brings all members of the healthcare team together, as well as the family members of the patients. The process started with physical therapists assessing the patient’s functionality and if they were at risk or not, and then assessing family member’s ability to assist the patient. A status of either red light, or green light was then assigned to each patient and their family to help further the nurse’s knowledge of which level of care needed to be administered. This was an ongoing process, and patients were repeatedly assessed in order to keep their status up to date. With this protocol in place, “the fall rate decreased from 8.8 falls per 1,000 patient days in 2009 to 3.8 falls per 1,000 patient days.” (Stubbs & Sikes, 2017)

This was implemented by making training sessions mandatory for all team members involved in patient care. New employees were also trained specifically in transferring patients, as well as with the equipment they would be using. Mandating training sessions allows for nurses to gain confidence before even seeing any patients, which will lead to sharpening their skills as well.

Implementing Change

The current system in place is that if a patient experiences a fall, an incident report is supposed to be filed. It is unknown if falls that do not result in any further injury are always reported. One way to ensure that patients are being treated fairly, and incidents are always reported is to have cameras within the rooms. This would ensure that nothing was missed, and can also be used for training purposes for new hires. There can be bi-weekly, or monthly progress meetings where a nurse meets with their managers and other members of the nursing leadership to review tapes of their actions.

Although cameras in patient rooms can be very beneficial, there are obstacles the hospital would need to go through to implement it. We would need patient consent for them to be watched under constant surveillance. Also, knowing you are being filmed can cause stress on the nurse, and may actually lead to more mistakes being made; especially in new graduates.

Conclusion

In regarding patient falls, it is obvious that something needs to be done. Besides the fact that reimbursement for falls doesn’t occur, but our patients need to feel safe in our hands. A patient who feels confident in their doctors, and nurses will feel hopeful, and work towards their goals of complete rehabilitation from their injury or illness. No one proposed solution has been proven to be the answer to all of our problems, but in picking and choosing from each theory we can come up with new protocols. Nurse leaders will be at the forefront of fall reduction, and will motivate their subordinates to partake in leadership roles as well. Our patients and their families will also play integral parts in their welfare, leading to a well-rounded and well thought out care plan. We need to help our patients to help ourselves in the long run.

References

Barker, A. L., Morello, R. T., Ayton, D. R., Hill, K. D., Brand, C. A., Livingston, P. M., & Botti, M. (2017). Acceptability of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomized controlled trial. PLoS One, 12(2) doi:http://dx.doi.org.library.capella.edu/10.1371/journal.pone.0172005

Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application. Philadelphia, PA: Lippincott Williams & Wilkins.

Murphy, L. M., Murphy, S. O., Hastings, M. A., & Olberding, A. (2015). Are interprofessional roundtable debriefings useful in decreasing ED fall rates? findings from a quality-improvement project. Journal of Emergency Nursing, 41(5), 375-380. doi:http://dx.doi.org.library.capella.edu/10.1016/j.jen.2015.02.005

Pelletier, L. R. (2014). Quality and safety. In D. L. Huber (Author), Leadership & nursing care management (pp. 291-321). St. Louis: Elsevier.

Quigley, Patricia A, PhD, MPH, CRRN,F.A.A.N., F.A.A.N.P., & White, Susan V, PhD, RN, CPHQ,F.N.A.H.Q., N.E.A.-B.C. (2013). Hospital-based fall program measurement and improvement in high reliability organizations. Online Journal of Issues in Nursing, 18(2), 19-5. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F1449497122%3Faccountid%3D27965

Stubbs, K. E., & Sikes, L. (2017). Interdisciplinary approach to fall prevention in a high-risk inpatient pediatric population: Quality improvement project. Physical Therapy, 97(1), 97-104. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F1862642901%3Faccountid%3D27965