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Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety.

The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle;  a "trial and learn" approach to improvement  based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009.

It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team.

The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to:

  1. The team's degree of belief that the change will result in improvement
  2. The risks from a failed test
  3. Readiness of those who will have to make the change

Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide: Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition.

Please refer to the Improvement Frameworks GSK (2015) for additional information.

Measurement Worksheets (Measures) and Data Collection Forms (DCF)

Measures DCFs
Aggregate data (monthly)De-identified Patient-level data (daily)
Numerator and DenominatorMultiple data elements
Roll-up to Measurement Worksheets

 

Falls Prevention Audit

The tool is designed for use in Acute, Long-Term, and Home Care, Supportive Living and Rehab and was developed to allow organizations to assess the quality of their falls prevention and injury reduction practices and determine the areas requiring quality improvement(s).

DCF (Audit) Question Roll-up to Measures
A. Type of Falls Risk Assessment performed on AdmissionFalls-Acute/LTC 3
B. Was patient/resident/client designated "at risk" for Fall and was risk status communicated?Falls-Acute/LTC 10
C. Medication review completed?Falls-Acute/LTC 11
D. Pt. has documented Falls Prevention/Injury Reduction PlanFalls-Acute/LTC 5
E. Completed Falls Risk Assessment following a significant change in medical statusFalls-Acute/LTC 12
F. Patient/Resident/Client is restrained at any time in this reporting periodFalls-Acute/LTC 6
G. How many times did the patient/resident/client fall in this reporting periodFalls-Acute/LTC 13
H. Was patient/resident/clients assessed for harm on discovery of fall?Falls-Acute/LTC 14
I. Harm from Fall?Falls-Acute/LTC 2
J. Completed Falls Risk Assessment following fall?Falls-Acute/LTC 15
K. Monitored for 24-48 hours after fall?Falls-Acute/LTC 16
L. Falls Prevention/Injury Reduction Plan Reviewed/Revised after Fall?Falls-Acute/LTC 17

 

Falls Prevention Audit Tools

Acute Care Long Term Care
Falls-Acute DCF - [PDF] Falls-LTC DCF - [PDF]
Falls-Acute Instructions - [PDF] Falls-LTC Instructions - [PDF]
Falls-Acute Score Template - [Excel] Falls-LTC Score Template - [Excel]

 

Falls (Acute Care) Measures

Measure Goal Type
Falls-Acute 1 - Falls Rate per 1000 Patient DaysReduce  40%Outcome
Falls-Acute 2 - Percentage of Falls Causing InjuryReduce 40%Outcome
Falls-Acute 3 - Percentage of Patients with Completed Falls Risk Assessment on Admission100%Process
Falls-Acute 4 - Percentage of Patients with Completed Falls Risk Assessment Following a Fall or Change in Medical Status 100%Process
Falls-Acute 5 - Percentage of "At Risk" Patients with a Documented Falls Prevention/Injury Reduction Plan 100%Process
Falls-Acute 6 - Percentage of Patients with Restraints Reduce baselineProcess
Falls-Acute 7 - Fall Related INJURY Rate per 1000 Patient/Resident DaysAnnual reduction of 40% or annual rate <= 0.3Outcome
Falls-Acute 9 - Percent of patients designated "at risk"Does Not applyProcess
Falls-Acute 10 - Percent of Patient designated 'at risk' and risk status communicated100%Process
Falls-Acute 11 - Percentage of patients with a medication review was completed100%Process
Falls-Acute 12 - Percentage of patients with Completed Fall Risk Assessment following Significant change in Medical Status100%Process
Falls-Acute 13 - Percentage of Patients with 2 or more falls0%Outcome
Falls-Acute 14 -Percentage of Patients Assessed for harm on discovery of fall100%Process
Falls-Acute 15 - Percentage of Patients with  Completed Fall Risk Assessment following a fall100%Process
Falls-Acute 16 - Percentage of "Fallers" with monitoring in place for 24-48 hours after the fall100%Process
Falls-Acute 17 - Fallers with review or revision of Falls Prevention / Injury Plan after fall100%Process
Falls-Acute 18 - Fall Prevention Score100%Outcome
Falls-Acute 19 - Fall Management Score (after fall)100%Outcome

Falls (Long Term Care) Measures

Measure Goal Type
Falls-LTC - Prevention of Falls in Long-Term Care Monthly ReportN/AInformation
Falls-LTC 1 - Falls Rate per 1000 Resident DaysReduce 40%Outcome
Falls-LTC 2 - Percentage of Falls Causing InjuryReduce 40%Outcome
Falls-LTC 3 - Percentage of Residents with Completed Falls Risk Assessment on Admission100%Process
Falls-LTC 4 - Percentage of Residents with Completed Falls Risk Assessment Following a Fall or Change in Medical Status 100%Process
Falls-LTC 5 - Percentage of "At Risk" Residents with a Documented Falls Prevention/Injury Reduction Plan100%Process
Falls-LTC 6 - Percentage of Residents with RestraintsReduce baselineProcess
Falls-LTC 7 - Percentage of residents physically restrained daily on the most recent RAI assessmentAt a minimum, to maintain at or below baselineOutcome
Falls-LTC 8 - Injury Rate Due to Falls (Fall-Related INJURY) per 1000 Resident DayAnnual reduction of 40% or annual rate <= 0.3Process
Falls-LTC 9 - Percentage of Residents Designated "At Risk"Does Not ApplyProcess
Falls-LTC 10 - Percentage of Residents Designated "At Risk" and Risk Status Communicated100%Process
Falls-LTC 11 - Percent of Residents With a Medication Review Completed100%Process
Falls-LTC 12 - Percent of Residents With Completed Fall Risk Assessment Following a Significant Change in Medical Status100%Outcome
Falls-LTC 13 - Percent of Residents With Two or More Falls0%Process
Falls-LTC 14 - Percent of Long-Term Care Residents Assessed for Harm on Discovery of Fall100%Process
Falls-LTC 15 - Percent of residents With Completed Fall Risk Assessment Following a Fall100%Process
Falls-LTC 16 - Percent of "Fallers" in Long-TermCare With Monitoring in Place for 24-48 Hours After Fall100%Process
Falls-LTC 17 - Percent of "Fallers" in Long-Term Care With Review or Revision of Falls Prevention/Injury Reduction Plan After Fall–100%Outcome
Falls-LTC 18 - Fall Prevention Score (Long-Term Care)100%Outcome
Falls-LTC 19 - Fall Management Score After a Fall (Long-Term Care)100%Outcome

Types of Measures

Safer Healthcare Now! (SHN) has two types of measures for each of the interventions: process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each.

Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls.

Process measures - processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection.

Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group.

Information measures - collect general details relative to the intervention.