The Journey to Uphold the Oath

In the summer of 2004, The Joint Commission, the largest accrediting body for health care organizations in the United States, released its yearly patient safety goals for the following year. For 2005, the goal related to fall reduction was twofold:

• “Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to address any identified risks.”

• “Implement a fall reduction program, including a transfer protocol, and evaluate the effectiveness of the program” (Geller & Guzman, 2005).

GWV had a fall prevention program in place for several years that addressed opportunities to reduce fall rates. This initiative came from best practices in fall reduction that had been publicized in nursing research and through other professional organizations, such as The Joint Commission and the Institute for Healthcare Improvement (IHI). GWV's Nursing Administration had also been active for some time in trying to reduce fall rates, but was never able to consistently reduce fall rates below the twenty-fifth percentile among NDNQI hospitals. Figure CS3.1 shows five years of data related to fall rates at GWV during this period.

It was not until the last quarter of 2011 and the first two quarters of 2012 that a significant reduction in fall rates began at GWV. The wake-up call came as the fall rate peaked at 5.46 falls per 1,000 patient days in June 2011. Nursing Administration felt a strong sense of urgency to reduce falls

GWVFall Rates, 2008-2012

Figure CS3.1 GWVFall Rates, 2008-2012

after the high rates were brought to the attention of the GHS board of directors. The board directed Nursing Administration to take the necessary steps to significantly reduce patient harm.

As a result of the board's call to action and recent consultations with the Studer Group, a health care consulting firm focused on operational, clinical, and financial outcomes, Nursing Administration took steps to home in on significantly reducing fall rates. Also during this time, GQI began working with the four units at GWV that had the highest fall rates in the hospital. The main focus initially was to look at safety rounds addressing the 5 P's. Observations by nurses and GQI showed that effective safety rounds were not being done reliably and consistently. For example, when a nurse entered a patient's room for rounding, it was not uncommon for the nurse or aide to ask, “How are you doing?” “Everything all right?” or “Can I get you anything?” This approach does not directly address the 5 P's.

A four-minute video focusing on the do's and don'ts for effective safety rounding was made, and all unit staff were shown the video and underwent a safety rounding seminar and certification conducted by Nursing Education. The seminar centered on how to ask direct questions related to the 5 P's. Questions such as “Are you in any pain?” “Can I help you to the bathroom?” “Do you need water?” “Are you comfortable in the position you are in?” and “Would you like to sit in the chair?” are the ones nurses need to ask patients. These direct questions address the areas that normally the patient is not thinking about unless he or she is asked directly. Effective questions are proactive; for example, informing the patient that he will be helped to the bathroom rather than asking if he needs to go to the bathroom.

Safety huddles are an important part of keeping patients safe. As mentioned previously, just about every quality improvement organization strongly encourages the use of huddles. In some GWV units, leaders decided that long team meetings were not engaging enough staff in improvement. So GQI led an effort to conduct safety huddles on each shift. Safety huddles were targeted at five minutes somewhere in the last half hour of the outgoing staff s shift. The huddles were always a hand off of knowledge from the outgoing to the incoming RN staff. Occasionally the aides would attend if they were not busy answering call bells or tending to other duties. The huddles, initially led by GQI staff, asked three questions:

1. Which patients are at risk for falls?

2. Why are these patients at risk for falls?

3. What is each patient's safety plan?

Most nurses acknowledged the benefit of taking time out of their busy routine to pause and focus solely on patients who were at risk. During the normal course of nursing reports, it may be mentioned that a patient is at risk, but the huddle focuses attention on all at-risk patients on the unit rather than just the ones the nurse is assigned to. The huddle can also be a great opportunity to discuss tests of changes or to relay important information to the entire group. Huddles are often times for a nurse manager, nurse leader, or charge nurse to recognize publicly the great work the staff is doing. The positive attitude that comes from this setting is powerful and can change the culture of a unit GQI then began to train the nursing leaders and charge nurses on the floor to conduct these huddles on their own. It is important to note that many times improvement initiatives start from the top (management) and come down, or they may even cut horizontally across the organization owing to the use of a consultative model like the GQI. However, the best and most effective way to achieve consistent improvement is by starting it from the ground up – among the nurses and staff working on the unit. If the frontline staff has bought into proposed changes that process improvement will bring about, they will personally make the necessary changes, ensure that others do so as well, and most important, guarantee that changes are sustained for time to come.

Nursing Administration support and accountability were integral to the success of this initiative. In June of 2011, Nursing Administration and the unit managers developed an action plan for immediate implementation. The plan covered the 5 P's, staffing, environmental rounds, change of shift procedures, bed alarms, safety huddles, and so forth. Another goal was to have weekly fall huddles among the unit managers and Nursing Administration. The chief nursing officer (CNO) and the vice president for nursing had been following the advice of the Studer Group to conduct weekly meetings or huddles that highlighted understanding challenges, transferring learning and best practices, rewarding and recognizing success, and holding leaders accountable for their results (Studer Group, 2007). However, after the meeting with the board, Nursing Administration began conducting daily live- to ten-minute huddles. Daily huddles created a sense of urgency throughout the entire organization to focus on fall reduction. As Margaret Hennelly-Bergin, the CNO at GWV, said about this initiative, “The key to improvement is to get the staff focused on one or two key things that will really lead to behavior change. We are asking our nursing staff to do a myriad of nursing tasks every day; they have so much on their minds. When they can direct their efforts on the one or two things related to fall prevention such as the 5 P's or safety huddles, it really helps to focus their attention on perfecting those particular tasks” (personal communication with the author, 2012).

The combination of using evidence-based practices more reliably and developing “cultural awareness” of fall prevention through leadership's communicating its heightened sense of urgency was the key determinant in enabling the great reduction in falls that has been sustained for nearly a year. In addition, the assistance that GQI offered as a third-party observer and facilitator was also essential to making the reduction in fall rates so successful. Other organizations should consider the use of a consultative model in which improvement specialists use a specific improvement methodology, such as PDSA, to help groups with important strategic initiatives. A third party's involvement can help groups to take an objective approach to improvement, as an outsider will have different perspectives and thoughts that can be very useful.

The overall reduction in falls was outstanding, and more specifically, the reduction in falls with injuries was also impressive (Figure CS3.2). It is

GWV Reduction in Falls with Injuries over a Two-Year Period

Figure CS3.2 GWV Reduction in Falls with Injuries over a Two-Year Period

estimated that by reducing falls with injuries, GQI helped GWV to avoid costs of over $375,000.

Conclusion

From its humble beginnings as a small hospital in rural Central Pennsylvania to its present status as one of the country's largest integrated health care systems, Geisinger has never forgotten its founder Abigail Geisinger's famous instruction that is now used as a slogan for the care that patients at Geisinger receive: “Make my hospital right; make it the best.” Her prescript goes along nicely with the Hippocratic Oath that health care providers take when beginning their careers. No matter what the circumstances may be, we do the best we can do to make patients better off when they leave our care than they were before they entered it – to have them heal physically, mentally, emotionally, and even spiritually.

It is human nature to make mistakes, but in health care, mistakes can sometimes be fatal errors. The nursing staff at GWV make a commitment every day to reduce the errors that can be made when caring for patients at high risk for falls. In 2011 and 2012, GWV has reduced fall rates by over 35 percent. That change was not just chance. It came from the commitment of every nurse to change the way he or she practices clinical care. Through increased reliability in following and practicing evidenced-based guidelines, increased accountability for staff and management, greater emphasis on innovative thinking, and increased physical and educational resources, the nursing staff at GWV is journeying onward to uphold the oath and truly provide the best care.

 
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