Clinical Practice Improvement Project Report: Importance Of Clinical Governance In Fall Prevention

Describe about the Clinical Practice Improvement Project Report.

Clinical governance is a systematic approach of improving and sustaining the quality of care provided to the patients in a health care system. Clinical governance is an important part in the health care system, as it helps to sustain the quality improvement and informs the deterioration in health care quality in a health care system.  In the United Kingdom National Health Service, clinical governance has been described as “A framework through which NHS organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish” (Haas and Haines 2014).  However, clinical governance includes three key aspects, transparent responsibility, high standard of care and accountability of that high standard of care. Here, in this project, the aim is to prevent the risk of fall, which is considered as one of the key responsibilities of nurses in a health care setting. It has been revealed that risk of fall and related injury is significantly high in the hospital patients. Thus, nurses need to gain sufficient knowledge and skills to prevent the risk of fall and related injury of the patients. One of the critical roles of clinical governance in health care is to identify the safety and security issues in the clinical performance and to improve clinical performance to eliminate those risks (Haines et al. 2014). Thus, preventing the risk of fall and related harm is relevant to the clinical governance in health care settings.

One of the key elements of clinical governance is education and training. Thus education and health promotion of the elderly people regarding fall and related injury is relevant to the clinical governance. According to the National competency standard for Registered Nurse in Australia provided by NMBA, “the registered nurses are accountable for recognizing the risk of falls” (Nursing and Midwifery Board of Australia 2013). The project aims to educate the patients about the fall prevention and to improve the clinical fall prevention measures by assessment and promotion of the fall prevention measures and education. The professional standards of Nurses included the standards, where it has been stated that nurses should make the clinical decisions including the patient’s perspective and should promote patient’s education. In addition, quality is the key skills of the registered nurses. Thus, the project topic is relevant to the clinical governance.

Evidence that the issue / problem is worth solving:

Fall and related injury is one of the most common and serious medical issue, which is most often experienced by the aged population, who are in the long-term hospital care. The Australian Commission of Safety and Quality in Healthcare has considered the falls as one of the largest harm-causing incident in the Australia for healthcare. Government and the national board have undertaken a number of initiatives to reduce the incidents of fall and related harms in elderly. It has been   revealed from the evidences that lack of knowledge, lack of support and proper supervision are the leading causes behind the fall and related risk. It has been revealed from the existing literatures that, 75% of the hip fracture patients, who are above 65 years old, have high risk of reduced health status due to fall related injury, especially, while residing in hospital or long-term residential care (Liu et al 2012). WHO documented that around 35% aged population more than 65 years old have a fall rate of 32-425 per year, which is increasing significantly (World  Health  Organization  2016). In addition, increasing fall rate is also enhancing the health care cost, which has been estimated as $6500 per fall related serious injury. In addition, the social dimension of fall related consequences include reduced independence of the patients, which has significant impact upon the victim’s family, friends and community. The Australian commission on Safety and Quality in Health Care provided several guidelines for fall prevention in different health care sectors. These policies and procedures include education and health promotional practices for improving the clinical care quality. Thus, from the evidences, it can be said that, the problem is worth solving. Thus, this project will include the proposed interventions and will be evaluated in the next part. It has been seen in evidences that there are different kinds of successful interventions for preventing falls in elderly people (Gillespie et al. 2012).

Evidence that the issue/problem is worth solving

In this project, each stakeholder have significant role in the success of the project. The key stakeholders include patients, nurses, patient’s family, health care organization management and the other health care staffs. Nurse Managers have significant role in implementing the successful intervention for reducing the fall rate of elderly person in the hospitals. Here, in this project, the aim is to educate patients and promoting their health. The patients, who are more than 65 years old and nurses have the most significant role in the project, as the stakeholders. It is because, the nurses are the one, who would educate patients and the patients are the one who would be educated regarding fall prevention. On the other hand, following the principles of person-centred care approach, the nurse managers would have the role of decision making and guiding the members, who are accountable for quality improvement in fall prevention in the healthcare system (Nadelson and Nadelson 2014). The patient’s family or other caregivers are responsible for reporting any kind of changes in the process during the intervention period.

CPI Tool:

CPI tool is the abbreviation of the “clinical practice improvement tool”, which are used for ensuring the improvement in the clinical practice implemented in the health care sector. There is several clinical practice improvement tools used in different clinical practice, but the tools or strategies relevant for the corporate business would not be suitable for the health care sectors. Thus, Plan-Do-Study-Act or PDSA tool has been implemented in this project. This clinical practice improvement tool is used for quality improvement projects, like the current project and in the research studies, which aim to introduce positive change in the health care process, promoting the positive outcomes. The purpose of this clinical practice improvement tool is to build a functional relationship with the change in processes and outcomes (Khong et al. 2015). The tool helps in gradual improvement upon a change implementation in a health care sector. Three key questions are answered through the PDSA tool, these are: 1) What is the project goal? 2) How will the goal be achieved using PDSA tool? And 3) What will be consequences after reaching the goal? In this project, the tool can be implemented gradually in the following way:

The first step in this process is to plan the change based on the identified issues, which needs change in the health care system. This step required ideas for improving the current situation or issues faced in the health care system. However, the ideas must align with the project aim and objectives, to assure the success of the plan (Koh et al. 2014).

The next step is ‘to do’, that means to implement the change in the health care context and document the consequences of the implemented change. In this step, any kind of unexpected change-related consequences should be recorded.

The third step includes ‘to study’, i.e. study the existing literature on the project topic, reviewing them and reflect on the analysis of data gathered in the previous step. In this process, the improvement related to the project interventions, which are also present in the literatures would enhance its reliability and other processes, which might have better outcomes would also be identified.

Key Stakeholders

The final step is ‘to act’. It is the step, where the interventions of smaller scale project are implemented in larger scale, if the outcomes of the smaller project meet the project objectives successfully. The successful project interventions are implemented in the health care settings for improving the clinical care quality (Department of Health 2010).

In this current project, PDSA has been used as it helps in gradual and systematic implementation of change in the health care setting. Here, the patient’s knowledge would be assessed, based on which appropriate health promotion and educational sessions would be implemented, to enhance their self-control and self-esteem, which would help the participant group to reduce the risk of fall (Gleeson et al. 2014). Here, the nurse manager a registered nurse would plan and guide the educational sessions, addressing the current issue.

According to Australian Commission on Safety and Quality in Health Care (2012) the PDSA tool is used for having the quantitative measures to reach the define goals. In the initial step, the multidisciplinary team will assess the fall rate and reports in last 3 months, in which hospital project will be implemented. The nurse managers in the multidisciplinary team will collect the fall related reports in the hospital, which would include the incident rate of falls and the factors promoting the risk of falls in the patients. In this project, the test group would be the aged people, who are more than 65 years old. Liu et al. (2012) showed successful educational interventions for older aduts, who showed significant benefit over the sessions. Hill et al. (2013) have shown the effectiveness of educational management of the older adult’s fall prevention in hospital settings. Here, the project will include three intervention steps; in the initial step, the registered nurses in the hospital will be assessed for their knowledge about the fall prevention and their role in educating patients about the fall prevention strategies. After assuring that the registered nurses have enough skills to educate patients about the fall prevention measures, the registered nurse would undergo a discussion about the fall prevention measures in the hospital. With the help of the information revealed from the group discussion, the intervention plan would be made. In this context, 30 patients, who are above 65 years old, would be selected randomly and they will be educated with 6 weeks educational sessions regarding the fall prevention measures along with a 4 weeks health promotion sessions regarding risk of fall and related hazard control, where the family members of the patients would also be allowed to participate. A questionnaire will be prepared for pre-test and post-test assessment. The pre-test assessment will be done before the educational sessions and the post-test assessment will be done after the educational sessions. The data will be collected after 1 week and the final data will be collected after completion of the 6 week sessions. Each questionnaire would include 20 questions (Liu et al. 2012). On the other hand, another proposed intervention would include 6 week fall prevention and gait-balance exercise sessions. Here, also pre and post test assessment would be done through physical test. Gianoudis et al. (2012) highlighted the protocol for the community-based multi-modal exercise program for older adults , which have successfully reduced their risk of falls. Valenzuela (2012) showed that the progressive resistnce training intervention can also help older adults to prevent falls.  In the initial steps, skilled trainers would be appointed upon assessing their training skills, which would be aligned with the questionnaire formed for the pre and post test assessment.

CPI Tool

Barriers to implementation and sustaining change:

In spite of the evidence-based intervention plans in this project, the projects have some barriers of implementation. Gleeson et al. (2014) claimed that lack of financial and team support from the nurse managers decreases the motivation level of the registered nurse. On the other hand, the lack of financial resources can lead to unavailability of the required devices and equipments for the successful intervention of the project. On the other hand, lack of teamwork has been noted as a significant factor affecting the change implementation, it is because, clinical health care activities are dependent on the cooperative nature of the multidisciplinary team, where  the medical care givers work depending upon each others. On the other hand, acceptance of the change implementation in a large scale, by the hospital management can also be a barrier of implementation and sustaining change.

Evaluation of the project:

The data gathered from the quantitative investigation through this project would be evaluated through the statistical analysis tools for assessing the improvement in the patient’s knowledge and self-esteem regarding the fall prevention strategies. The data would again be collected after 3 months of the project completion, for collecting the follow up data. It would enhance the reliability of the project findings. In this study, positive result is collected from the intervention, showing improved patient knowledge regarding the fall prevention measures and risk assessment.

Reference List

Australian Commission on Safety and Quality in Health Care 2012, National Safety and Quality Health Service Standard, Commonwealth of Australia.

Department of Health 2010, The Plan Do Study Act (PDSA) Model for Improvement Project Workbook, viewed 23rd August 2015 <https://www.health.vic.gov.au/pch/downloads/pdsa_model_improvement_workbook.pdf>

Gleeson, M, Sherrington, C and Keay, L 2014,’ Improving Balance and Mobility in people over 50 years of age with vision impairments: can the Alexander technique help? A study protocol for the visibility randomised controlled trial’, Pubmed, vol 20. 

Koh, SS, Manias, E, Hutchincsin, AM, Donath, S and Johnston, L 2008,’ Nurses’ perceived barriers to the implementation of a fall prevention clinical practice guideline in Singapore hospital’, BMC Health Service Research, vol.8, pp.1-10.

Liu, H, Shen, J and Xiao, LD 2012,’ Effectiveness of an educational intervention on improving knowledge level of chinese registered nurses on prevention of falls in hospitalized older people- A randomized controlled trial’, Nurse Education Today, vol. 32, pp. 695-702.

Nursing and Midwifery Board of Australia 2013, National Competency Standards for the registered nurse, Australia.

Haas, R. and Haines, T.P., 2014, ' Twelve month follow up of a falls prevention program in older adults from diverse populations in Australia: A qualitative study' , Archives of gerontology and geriatrics, vol 58, no. 2 , pp.283-292.

Haines, T.P., Day, L., Hill, K.D., Clemson, L. and Finch, C., 2014, ' Better for others than for me: A belief that should shape our efforts to promote participation in falls prevention strategies' ,  Archives of gerontology and geriatrics, vol 59, no. 1, pp.136-144

Khong, L., Farringdon, F., Hill, K.D. and Hill, A.M., 2015, ' We are all one together”: peer educators’ views about falls prevention education for community-dwelling older adults-a qualitative study ', BMC geriatrics, vol 15, no.1 , p.1.

Nadelson, S. and Nadelson, L.S., 2014, ' Evidence?Based Practice Article Reviews Using CASP Tools: A Method for Teaching EBP ',  Worldviews on Evidence?Based Nursing, vol 11, no.5 , pp.344-346.

World  Health  Organization  2016,  Falls Prevention in Older Age, viewed 29th August 2016,

https://www.who.int/ageing/projects/falls_prevention_older_age/en/

Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Sherrington, C., Gates, S., Clemson, L.M. and Lamb, S.E., 2012. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev, 9(11).

Gianoudis, J., Bailey, C.A., Sanders, K.M., Nowson, C.A., Hill, K., Ebeling, P.R. and Daly, R.M., 2012. Osteo-cise: strong bones for life: protocol for a community-based randomised controlled trial of a multi-modal exercise and osteoporosis education program for older adults at risk of falls and fractures. BMC musculoskeletal disorders, 13(1), p.1.

Valenzuela, T., 2012. Efficacy of progressive resistance training interventions in older adults in nursing homes: a systematic review. Journal of the American Medical Directors Association, 13(5), pp.418-428.

Liu, H., Shen, J. and Xiao, L.D., 2012. Effectiveness of an educational intervention on improving knowledge level of Chinese registered nurses on prevention of falls in hospitalized older people—A randomized controlled trial.Nurse education today, 32(6), pp.695-702.

Hill, A.M., Etherton-Beer, C. and Haines, T.P., 2013. Tailored education for older patients to facilitate engagement in falls prevention strategies after hospital discharge—a pilot randomized controlled trial. PloS one, 8(5), p.e63450.