STAKEHOLDER ANALYSIS

Teba L Seaborn

Manage Discussion Entry

Action steps must be taken to implement an improved practice plan. For this safety and quality improvement practice project on fall prevention, our team will use a plan-do-study-act (PDSA) model to plan a change, test the change, analyze results, and modify changes if needed (Spath, 2018). We will add a fishbone diagram to determine which interventions are a priority for the facility. A bar graph will be added to help staff visualize the impact of facility falls and how many have occurred in five months (Spath, 2018). A chart to compare baseline falls to post-intervention fall rates will be used to evaluate the results.

Current data identifies a lack of patients with regular fall-risk assessment or history as the most significant contributing factor to falls in our facility. Assessing each patient's history of falls and fall risks gives clinicians an early preventive approach. According to the American Geriatrics Society (2017), all geriatric patients should be screened for fall risks during routine clinical visits. The facility policy states that each patient should be assessed on admission and quarterly to reduce falls.

The Centers for Medicare & Medicaid Services has updated Conditions for Coverage for the dialysis patient's reimbursement, and all newly admitted patients in a dialysis center must have an initial fall-risk assessment completed per regulations (Fehlberg et al., 2017).

In my facility, chairside charting is done on paper. A fall risk check-off tab has been added to the flowsheet of eight patients with previous falls. The pre-treatment assessment nurse must check off when a fall-risk assessment has been performed, and proper documentation should follow. After data evaluation, if it is determined that those eight patients had the highest documentation compliance as expected, that change will be implemented facility-wide.

Adding a check sheet area to the patient flowsheet will benefit the facility stakeholders and add no financial burden. The practice plan is currently very cost-effective. Resources needed to carry out the project and solve the problem are proper staffing-to-patient ratios and hours allocated for formal staff education sessions. The unit charge nurses will lead education sessions on documentation which will cut down administrative costs of bringing in a trainer. Cost may occur in the form of extra hours incurred by hourly staff entering the flowsheets into the EHR and attending in-service meetings.  

After sharing the improvement project with my mentor and charge nurses, we collectively agreed that the steps of the improvement plan would have to occur as a group effort. The documentation and policy changes will affect the technicians, licensed practical nurses (LPNs), registered nurses (RNs), dietitians, social workers, and patients. Research suggests that multidisciplinary approaches to fall management help decrease fall risks (Nelson & Reynolds, 2015). Gathering clinicians from different disciplines on a team does not guarantee cohesive collaboration (Kotecha, 2015). 

Change can be challenging, but it is inevitable for success (Drake, 2020). In this project, some of the barriers identified were time constraints due to fast-paced shift turnover, lack of staff compliance, and motivation to ensure documentation was done for every patient. Most of the staff needed more incentive to accept this change. Multiple team members voiced their concerns about the hard shift change, remembering to check each patient and ongoing staffing issues that would deter documentation compliance.   

To address staff resistance, we will apply the Prosci ADKAR model to our improvement plan to engage staff in the planned changes. This model was developed by Jeff Hiatt, who studied over 700 organizations' change patterns, and is used by several global change leaders. It is individual-specific and helps guide a person through a particular change, analyze it, and address any roadblocks or barriers to success (Drake, 2020). The implementation actions will occur as follows:

ADKAR

· Awareness-communicate to the staff why the fall-risk documentation changes are necessary. Informed staff are more receptive to changes.

· Desire-Assess the group's desire to change processes.

· Knowledge-Provide education on documentation importance and accuracy. Knowing how to document effectively will decrease the fear of change or the unknown.

· Ability-gauge their ability to implement the change

· Reinforcement-Celebrate successes and provide leadership reinforcement to sustain the change (Drake, 2020).

Weekly poster reminders are already in place throughout the clinic. Patients are getting involved in their care more and asking questions about falls relating to themselves and loved ones. Charge nurses are encouraged to check the flowsheets for check-offs during their daily chair rounding and intervene as needed. A leader will be appointed to help champion and get staff excited about the safety goal. The nurse practitioner is buying-in into the project and is reinforcing fall education during her rounds when she can.

A lack of time and staff resistance are potential stumbling blocks that could hinder this project from adopting a long-term change. After intervention implementations, we project full future participation and a safety plan that will increase patient satisfaction, provide favorable outcomes and enhance the quality of care.

References:

American Geriatric Society. (2017). AGS/BGS Clinical Practice Guideline: Prevention of falls in older adults. Retrieved from,  http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendationsLinks to an external site.

Drake, K. (2020). Change is inevitable.  Nursing Management (Springhouse) 51(7): p 56, | DOI: 10.1097/01.NUMA.0000669092.10582.06 

Fehlberg, E. A., Bakken, S., Weaver, M. J., McDaniel, A. M., Chandler, A., Richey, P. A., Mion, L. C., & Shorr, R. I. (2017). Impact of the CMS No-Pay Policy on Hospital-Acquired Fall Prevention-Related Practice Patterns.  Innovation in Aging,  1(3).  https://doi.org/10.1093/geroni/igx036Links to an external site.

Kotecha, J., Brown, J. B., Han, H., Harris, S. B., Green, M., Russell, G., . . . Birtwhistle, R. (2015). Influence of a quality improvement learning collaborative program on team functioning in primary healthcare.  Families, System, & Health, 33(3), 222-230. doi: 10.1037/fsh0000107

Nelson, E., Reynolds, P. (2015) Inpatient Falls: Improving assessment, documentation, and management BMJ Open Quality;4:u208575.w3781. doi: 10.1136/bmjquality.u208575.w3781

Spath, P. (2018).  Introduction to healthcare quality management (3rd ed.). Health Administration Press.