NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision NURS-FPX 6212 Health Care Quality and Safety Management ​​​​​​​Planning for Change: A Leader’s Vision 

Background of Systemic Problem 

Inpatient falls represent a systemic problem within ___________ (mention the organization), accounting for 30 fall incidents per 1,000 patient days. This problem poses significant risks to patient safety and well-being, such as fall-related injuries, additional costs, psychological distress, and poor quality of life (LeLaurin & Shorr, 2020). Along with the intrinsic contributing factors, some performance gaps reveal insufficient preventive measures, a lack of safety culture, and reduced staff adherence to fall prevention protocols within the organization. Thus, a quality and safety plan is proposed to reduce fall rates and alleviate poor consequences.

Plan to Enhance a Culture of Safety Within Our Organization

The practice changes designed for __________(mention the organization) aims to increase fall prevention efforts, reduce inpatient fall rates, improve patients experiences, and enhance a safety culture within the organization. These fundamental changes include: 

Comprehensive Fall Risk Assessment Protocols

This involves the use of standardized protocols for fall risk assessment. According to Strini et al. (2021), standardized fall risk assessment protocols, such as the Morse Fall Scale and Hendrich II Fall Risk Model, are beneficial for organizations to identify high-risk populations, guiding preventive efforts. Through this practice change, we aim to enhance fall risk assessment practices among healthcare providers at the time of admission and during patients’ stay in the hospital to make necessary modifications based on patients’ conditions. 

Staff Education and Training

Next, the plan is to implement educational interventions. These staff training and education initiatives will improve the quality of staff practices, primarily related to inpatient falls. By creating awareness, the organization can close the performance gap of non-compliance with fall prevention protocols (Shaw et al., 2020). Ultimately, these training and education programs will enhance patient safety and reduce adverse outcomes.

Multidisciplinary Fall Prevention Teams

Lastly, the plan entails the establishment of an interprofessional fall prevention team comprising physicians, nurses, pharmacists, physical therapists, and environmental specialists. These team members will provide diverse expertise to guide fall prevention interventions tailored to patients’ needs and organizational objectives. These teams will collaboratively facilitate comprehensive fall risk assessment, implement interventions, and monitor the efforts for ongoing quality improvement (Gemmeke et al., 2022). 

Existing Organizational Functions, Processes, and Behaviors 

Now, we will discuss how the existing organizational functions, procedures, norms, policies, and staff behaviors affect the quality of care and patient safety within our organization, significantly augmenting in-patient fall rates. The lack of comprehensive fall risk assessment procedures is a primary organizational lapse that increases in-patient falls. For instance, inconsistent fall risk assessment protocols may result in missed opportunities to effectively identify and address patient fall risks (Appeadu & Bordoni, 2023). Additionally, environmental factors such as inadequate lighting and crowded walkways are hazardous practices within the organization, heightening fall risk for high-risk patient populations. Similarly, behavioral inefficiencies of communication gaps among health providers and lack of staff adherence to fall prevention strategies increase the likelihood of in-patient falls. This results from insufficient practices and coordination failures (Turner et al., 2022). 

Addressing these aspects can contribute to building reliability and high-performing organizations by focusing on several key strategies, such as standardizing fall risk assessment protocols and ensuring comprehensive staff training on fall prevention strategies. Secondly, creating a sense of accountability and continuous learning by fostering open communication channels and interdisciplinary collaboration among healthcare teams. Additionally, making environmental modifications to create safer care environments and mitigate fall risk factors (Stathopoulos et al., 2021). 

Knowledge Gaps and Areas of Uncertainty 

Despite knowing the organization’s functions and behaviors impacting quality and safety, there remain knowledge gaps and areas of uncertainty. The knowledge gaps exist related to the best practices that have positively affected the organization. There are uncertainties surrounding the optimal utilization of technology in identif