Quality leader focuses on compliance

Approach results in reduction in fall rates

Many times it takes significant changes in processes and/or policies to effect improvements in quality performance. But before undertaking any initiatives, Jeffrey Weinberg, MD, a physical medicine and rehabilitation specialist at Staten Island (NY) University Hospital, opted for a different approach when addressing fall prevention.

"What we decided was rather than continually trying to develop new policies and protocols in response to increased fall rates or sentinel events, we said, 'Let's make sure everyone is following all our policies,'" he says.

"So, when someone had a fall we looked at the incident reports and then at the charts, and we found the policies were not being followed as rigorously as they could be to truly prevent a fall," Weinberg continues. "So we said, rather than changing things, let's set a process in place that holds people more accountable for following existing protocols, and only change them when we're sure people are following those and a new protocol could supplement them."

Two phases

The approach has clearly worked. In a paper published in the Joint Commission Journal on Quality and Patient Safety, Weinberg and his colleagues reported that over a four-year period inpatient fall rates decreased by 63.9%; minor and moderate fall-related injuries decreased by 54.4% and 64.0%, respectively. Two falls with major injury occurred during the study.1

The initiative was comprised of two phases, the first being the review phase. Weinberg and his colleague Donna Proske co-chaired this effort, first reviewing existing policies. "We thought they were okay," he recalls.

This phase also included chart reviews. "Early on there were so many falls we couldn't do it with every fall, but with minor or moderate injuries we would call the manager and staff nurses to a meeting where we all reviewed the charts together," Weinberg says. The attendees included the vice president of nursing; quality management; the associate vice president of nursing for that particular area; the nurse manager; the staff nurse; and sometimes a nurse's aide.

"We basically took the incident report and went through and challenged everything," says Weinberg. This included whether important procedures were conducted on every shift — for example, if the patient was checked on frequently to make sure they did not climb out of bed. "We found there were often lapses in compliance with the fall prevention protocols," notes Weinberg.

The main factor that helped to reduce the falls, Weinberg asserts, was a process whereby the protocol breaches were clearly identified and the people who committed the breaches were held accountable.

Enforcing accountability

One concern, Weinberg continues, was that the nurse manager on the unit be able to determine as quickly as possible when staff was not following protocols, so fall prevention rounds were quickly instituted.

"We determined we would handle these situations initially with education, then progressive disciplinary action — but we did not find we had to get to that level," says Weinberg. "Basically through education and awareness, and also by being identified, people got with the program."

Weinberg says people were not ignoring policy because they were lazy, but because "This is a very busy place and you have to set priorities." Accordingly, he continues, "We made sure fall prevention was a priority, and we put in a structure to reinforce that message at every level."

So every morning the nurse manager would review fall prevention assessments and strategies implemented on the unit. "If there was a fall and say, for example, the patient assessment was not done correctly or care was not planned properly, we'd go to the nurse manager and ask if they picked that up on rounds — so then they became accountable," Weinberg shares. "What that did was not only hold them accountable, but it made people become more aware of the situation. Prior to this, people saw fall rates go up even though it seemed to them people were following protocols."

In many cases, says Weinberg, it came down to a lack of critical thinking. "We empowered people to think differently," he says. "For example, take someone who was initially not at risk for a fall; they had been assessed properly, and we did not have fall prevention protocols in place. At that point, this may have been appropriate, but then they received, perhaps, a dose of tranquilizer: that should have triggered critical thinking where someone could have suggested the patient be put on fall prevention for the next four hours. We wanted everyone to be aware of the importance of critical thinking, and make sure that reasonable efforts were being implemented in a thorough and complete way."

Adding protocols

Once compliance improved, Weinberg and his team turned to new protocols. "We formalized the use of bed alarms and chair alarms," he says. "Although they used to be used sporadically we set up criteria that resulted in them being much more widespread." Now, he says, whenever a patient gets up an alarm goes off. "Even here, however, just putting in a protocol is not enough," he emphasizes. "When it started we were not 100% compliant, so in doing our reviews we identified where it should have been done — and in a short period of time it was being used appropriately."

In addition, while there had been some prior efforts to assist with toileting, "we put in a strict protocol that patients at risk had to be offered toileting every two hours while awake," Weinberg says. "But again, it's more than just saying that's our policy, but reminding people that we are monitoring compliance. Following up with accountability led to much more compliance and further reductions in falls."

In addition, he notes, success has bred success. "As we became successful and reversed the trend of increased falls people became enthusiastic about the program; there was friendly competition among the units, who also shared best practices. It evolved from being burdensome to being something people became very proud."


  1. Weinberg, J, Proske, D, Szerszen, A, Lefkovic, K, et al. An Inpatient Fall Prevention Initiative in a Tertiary Care Hospital. Joint Commission Journal on Quality and Patient Safety, Volume 37, Number 7, July 2011, pp. 317-2AP(-314).