Here is the Situation of Black Elk Medical center (BEMC), which is a quality-driven acute care hospital organization that includes three medical facilities that treat both inpatients and outpatients. BEMC has won numerous national and local quality awards. These included the J.D. Power awards in 2009 and 2011, First in Kentucky and Ohio in Hospital Quality Award by Anthem Insurance Co., and a listing as one of the Top Ten Hospitals. Black Elk's mission statement says: "We will strive for excellence in all services we provide compared to national standards." In 2012, the Board of Trustees for Black Elk Medical Center set a goal to reduce the fall rate within the hospital nursing units below the national norm, defined by one national benchmark as 3.4 falls/1000 patient days. The current organizational fall rate for 2011 averaged 4.8 falls/1000 patient days and through first six months of 2012 average fall rate averaged 4.75 falls/1000 patient days. The fall rate at any health care institution is significant to elderly patients, and especially so to those that are 65 years of age and older. Many elderly patients fall, break a hip, or even die within one year of the fall. The Board set the fall reduction goal in conjunction with a new regulation, National Patient Safety Goal 9B, that stated that health care organizations must implement a fall reduction program and evaluate the effectiveness of the program no later than January 1, 2013. Each health care organization was required to create or adopt a fall risk assessment process specific to the population served. The Joint Commission on Accreditation of Healthcare Organizations (JACHO) does not define a fall. Each health care organization must operationally define what they consider to be a fall, while meeting individual states' rules and regulations. The level of injury or type of injury must be Tracked and documented to avoid counting near misses as falls. All age groups must be assessed for the risk of falling, not just the geriatric population. The health care organization also had to determine when the initial fall risk assessment was performed and the time frame for reassessments. Reassessments should be per- formed when a patient's condition changes, the patient is moved to another level of care, or when medications are ordered for the patient that would increase the risk of falling. An 11-member interdisciplinary Fall Prevention Task Force was formed with representatives from Nursing, Facilities, Safety, Quality Management, Housekeeping, Plant Engineering, and Accreditation Services. The scope of the project was to assess the operations and environment at BEMC for actual or potential change to protect patients from accidental falls. The committee chair, Maureen Hebert, is the Long Term Care Administrator and has worked at Black Elk for over 18 years. Her responsibility includes providing patient care from acute care through a continuum of programs that include hospice, and long term care.
Suppose that you were consulting for this organization. What would your next steps be? How would you use data gathered from the checklist? How would you design improved processes and systems to improve and control the incidence of falls, and to effectively and rapidly reduce the fall rate to be below 3.4 falls/1000 patient days?