2. 2
QI Change Process
• Change process strategies
can be applied to other
quality improvement efforts:
– Hospital-acquired pressure
injuries
– Catheter-associated urinary
tract infections
– Deep vein thrombosis or
pulmonary embolism
following knee and/or hip
replacement
– Blood incompatibility
3. 3
Module 2 Goals
• Identify actions needed to improve organizational
readiness.
• Maximize the possibility of successful
implementation by addressing these questions:
– How can you set up the Implementation Team for
success?
– What needs to change, and how do you redesign
practice?
– How should goals and plans for change be developed?
– How do you bring staff into the process?
4. 4
Expected Outcomes of Module 2
• Finalize Implementation Team members and
assign roles. (Tool 2A)
• Present the completed process analysis on
one patient care unit. (Tool 2C)
• Present the assessment of current fall
prevention policies and procedures. (Tool 2D)
– Team Leader or designee completes assessment
and folds recommendations into the Action Plan.
6. 6
Implementation Team Guidelines
• How often will you meet?
• What are the ground rules for managing
meeting time and communication?
– How will you communicate with each other?
– How will you communicate successes?
• How will the Team do its work?
– Small group work
– Working meetings
8. 8
Successful Implementation Team
• A strong link to hospital leadership
• Members with the needed expertise (Tool 2A)
• Access to resources needed to accomplish
the aim
• Links to quality improvement expertise
• Members who influence the areas involved in
fall prevention
9. 9
Interdisciplinary Team
Tool 2A
Part 1: Team Members – You are the core Implementation Team
Position/Discipline
Names of Possible Implementation Team
Members From Each Area Area of Expertise
Nursing
Staff nurses
Nursing assistants
Rehabilitation
Physical therapists
Occupational therapists
Prescribing Clinicians
Physicians (e.g., hospitalist)
Other providers (e.g., nurse practitioner or
physician assistant)
Pharmacy
Pharmacists
Facilities and Environment
Materials manager
Environmental services staff
Facilities engineer
Managers
Senior manager
Quality improvement/safety/risk manager
Reference: Developed by Falls Toolkit Research Team.
10. 10
QI Process
• Link the Fall Prevention Program with quality
improvement.
– This information helps you define resources your
hospital has for quality improvement.
• Plan, Do, Study, Act (PDSA) is one systematic
approach to analysis and implementation.
Tool 2B
Page 21
11. 11
QI Process
• Your Implementation Team Leader
has filled out many assessment
forms already.
• We’ll be working to find
solutions for positive change.
• Let’s hear from your
Implementation Team Leader
now about your hospital’s
QI program and how to
link with QI.
12. 12
Assess Current Prevention Processes
• Use process mapping to examine
key processes on selected units.
• Analyze the process maps.
– Do your processes incorporate best practices?
(See Module 3.)
– Which practices need changing?
– How should processes be changed to build in the
new practices?
Tool 2C
16. 16
Current Process Analysis
• Let’s hear from the Team members who
completed the process analysis.
– Share process analysis from the unit.
– Point out key processes being used.
18. 18
Assess Current Policies
• The Implementation Team Leader identified the
policies in place and areas for improvement.
• You’ll want to address these areas in the Action
Plan.
• Then, we will compare this assessment with
best practices in Module 3.
– A group you designate may opt to do further
fine tuning at a later time.
– Let’s look at the completed Tool 2D now.
20. 20
Staff Knowledge Assessment
• Who will administer Tool 2E?
• How will it be administered?
• Who will be in charge of assessing the results?
21. 21
Implementation Action Plan
• The implementation Action Plan for change
should address the following:
– Membership and operation of the Implementation
Team
– Standards of care and practices to be met
– How gaps in staff education and competency will
be addressed
22. 22
Implementation Action Plan
• The Action Plan also addresses:
– Plans for rolling out new standards and practices,
where needed
– Staff accountable for monitoring the
implementation
– How changes in performance will be assessed
– How this effort will be sustained
23. 23
Action Plan
Tool 2F
Key
Interventions/Tasks Steps To Complete Task and Tools To Use
Team Members Responsible for
Task Completion
Target Date for Task
Completion
Examples Examples Examples
1. Analyze current
state of fall
prevention
practices in this
organization.
Identify strengths and weaknesses using process mapping
and gap analysis. Tool 2C and Tool 2D.
Team leader, RNs Within 6 weeks from
initiative start
Assess the current state of staff knowledge about fall
prevention. Tool 2E.
Education department Within 6 weeks from
initiative start
Set target goals for improvement. QI department Within 8 weeks from
initiative start
2. Identify the set of
prevention
practices to be
used in
redesigned
system.
Determine how comprehensive universal fall precautions
should be performed.
Implementation Team Within 12 weeks from
initiative start
Decide which scale or questions will be used for performing
fall risk factor assessment.
Implementation Team Within 12 weeks from
initiative start
Decide which fall prevention activities should be in your
program.
Clinical staff members Within 12 weeks from
initiative start
3. Assign roles and
responsibilities
for implementing
the redesigned
fall prevention
practices.
Determine who will complete the fall risk factor assessment
on admission. Tool 4A.
Implementation Team Within 16 weeks from
initiative start
Identify unit champions. Team leader Within 16 weeks from
initiative start
Determine how prevention work will be organized at the
unit level, such as paths of communication and lines of
oversight.
QI team Within 16 weeks from
initiative start
4. Put the
redesigned set
into practice.
Engage staff and get them excited about the changes needed. Team leader, unit staff Within 12 weeks from
initiative start
Pilot test the new practices. QI department Within 20 weeks from
initiative start
5. Monitor fall rates
and practices.
Determine how incidence data on fall rates and fall
prevention care processes will be collected. Tools 5A and
5B.
QI department Within 6 weeks from
initiative start
Organize quarterly reviews of data. QI department Within 6 weeks from
initiative start, ongoing
Reference: Adapted from material produced by MassPro, a participant in the Centers for Medicare & Medicaid Services Quality Improvement
Organization Program.
24. 24
Action Plan Example – Key Intervention 1
Key Tasks Steps To Complete Task and Tools To Use
Person
Responsible
Target Date for
Task Completion
Date
Completed
Analyze Readiness for Change Tool 1E Resource Needs Assessment Mary and Jack April √
Tool 2A Interdisciplinary Team Assessment Mary and
Jackie
April √
Tool 2B Quality Improvement Process
Assessment
Susan and Jack April √
Analyze Current Fall
Prevention Practices
Identify strengths and weaknesses using
process mapping and gap analysis. Tool 2C and
Tool 2D.
Susan and
Cathy
April √
Tool 4C Assess Staff Education and Training Peggy and Jim April √
Determine How Risk Is
Identified
Present R, Y, G definitions and get Team buy-in. Team June √
Get Team buy-in on who does risk assessment
and when (Nursing/4 hours).
Team June √
Define levels of independence. Team September
Determine how to communicate independence
level when patient is Green (i.e., wheelchair or
standing level).
Team September
Determine how to communicate if patient can
be in room alone in wheelchair when Red/High
risk.
Team September
25. 25
25
Action Plan
Reference: Adapted from material produced by MassPro, a participant in the Centers for Medicare & Medicaid Services Quality Improvement
Organization Program.
Key
Interventions/Tasks Steps To Complete Task and Tools To Use
Team Members Responsible for
Task Completion
Target Date for Task
Completion
Examples Examples Examples
1. Analyze current
state of fall
prevention
practices in this
organization.
Identify strengths and weaknesses using process mapping
and gap analysis. Tool 2C and Tool 2D.
Team leader, RNs Within 6 weeks from
initiative start
Assess the current state of staff knowledge about fall
prevention. Tool 2E.
Education department Within 6 weeks from
initiative start
Set target goals for improvement. QI department Within 8 weeks from
initiative start
2. Identify the set of
prevention
practices to be
used in
redesigned
system.
Determine how comprehensive universal fall precautions
should be performed.
Implementation Team Within 12 weeks from
initiative start
Decide which scale or questions will be used for performing
fall risk factor assessment.
Implementation Team Within 12 weeks from
initiative start
Decide which fall prevention activities should be in your
program.
Clinical staff members Within 12 weeks from
initiative start
3. Assign roles and
responsibilities
for implementing
the redesigned
fall prevention
practices.
Determine who will complete the fall risk factor assessment
on admission. Tool 4A.
Implementation Team Within 16 weeks from
initiative start
Identify unit champions. Team leader Within 16 weeks from
initiative start
Determine how prevention work will be organized at the
unit level, such as paths of communication and lines of
oversight.
QI team Within 16 weeks from
initiative start
4. Put the
redesigned set
into practice.
Engage staff and get them excited about the changes needed. Team leader, unit staff Within 12 weeks from
initiative start
Pilot test the new practices. QI department Within 20 weeks from
initiative start
5. Monitor fall rates
and practices.
Determine how incidence data on fall rates and fall
prevention care processes will be collected. Tools 5A and
5B.
QI department Within 6 weeks from
initiative start
Organize quarterly reviews of data. QI department Within 6 weeks from
initiative start, ongoing
Tool 2F
26. 26
Managing Change Checklist
Tool 2G
Implementation Team composition
Team leader identified and in place
Members with necessary expertise/role identified and invited
Linkage to senior leadership defined and established
Team startup
Team agenda and charge clearly stated
Necessary training and resources in place for team to get started
Assessment
Current state of fall prevention practice and knowledge assessed
Current practice and policies systematically examined
Challenges to good practice identified at organization and unit levels
Reference: Developed by Falls Toolkit Research Team.
