Our intervention resulted in a sustained reduction in falls below the national average over a 24-month period, falling from 3.41/1000 BDOC in FY 21 to 2.29/1000 BDOC through FY 22. The National Aggregate falls rate for FY22 was 4.06/1000BDOC. Daily reporting was critical. Future directions include SPC charts for sustainment. This presentation reports the results of a systematic fall prevention program initiated at the Greater Los Angeles VA Healthcare System, a complex 1A facility, that has resulted in a sustained reduction in falls significantly below the national average over a 24-month period, falling from 3.41/1000 BDOC in FY 21 to 2.29/1000 BDOC through FY 22. The National Aggregate falls rate for FY22 was 4.06 BDOC. A preliminary analysis of interrupted time-phase data indicates that injury rates across all unit types has been significantly reduced in contradistinction to previous studied indicating only a reduction in falls.
Problem: After recognizing an increase in both falls and percent falls with major injury, a systematic falls prevention program was implemented to achieve the strategic goal of reducing facility fall rates
Measurement: Falls are measured as a rate based on bed days of care. We measured falls over time as a rate and as a percentage based on major injury. We also used stoplight reports to compare against published comparators
Analysis: Given how well-studied this issue is in the literature, we were able to refer to documented rates to set targets. Additionally, as part of a large, national healthcare system, we were able to compare our data with comparable facilities
Implementation: Our team will demonstrate a multi-modal implementation strategy that includes simple interventions, checklists, technology solutions, EMR tools, communication/handoff tools, safe patient handling equipment, visual cues, and other solutions. Along the way, we had to update policies, change falls committee focus, review literature, and engage leadership to ensure prioritization.
