Clinical Audit Proposal For Fall Prevention In Local Hospitals

Stakeholder identification and involvement in the audit process is an absolute necessity. Both internal and external stakeholders can be recruited for the current audit process. While the internal stakeholders involve the healthcare staff’s and patients, the external stakeholders involve industry experts and consultants. Therefore, the audit proposes to identify how many stakeholders are involved in the process of fall prevention strategy involvement. There must be balance in representation of stakeholders in the audit process (Stephenson et al., 2017).

The administrative staffs and board of members must be included in the audits that support the change. If required external consultants from local hospitals having experience in fall prevention audit must be included in this process.

The audit proposes the quality officer along with one person from administrative department and one person from healthcare professional representatives must conduct the audit. However, prior to audit process the staff’s and employees must be intimated about the process and the persons who will be involved in this process. Suggestions and recommendations must be taken into consideration as this can seriously impact the adherence to audit process.

The monitoring and evaluating team must consist of two members from each section such as board, management, health care professionals, employee union and patient representative. Prior to formation of team and post formation of team, review meetings must be conducted. The team members must know each other and any type of conflict of interest must be sorted out prior to evaluation and monitoring process implementation. Communication within the team must be maintained either through intranet mail system or through any particular online or offline group formation (Phelan et al, 2016).

The above-mentioned steps complete the stage 1 of the clinical audit process that set the platform for fall prevention audit.

Identifying the problem in the chosen setting

The process of measuring the standards and quality of care provided to consumers is called clinical auditing. It also involves bringing into the limelight area that has well performed as well as areas calling for improvements. Additionally, by creating awareness of the hospital’s performance in certain areas and the right courses of actions that could be implemented to improve the status of care practice, patients are empowered. The overall target of clinical auditing is improving the quality of care in targeted units that are deemed most helpful and addresses patients

outcomes. Clinical auditing can be conducted at two levels i.e. the local level and the national level (Hatambadi et al., 2016). At the national level, auditing focuses on care provided at the national level while the local clinical audit is more concerned on improvements in a particular area at local hospitals. Due to the high number of the aged population in Australia, falls has become one of the leading challenges in the country’s healthcare system. Statistics from various hospitals indicate that occurrence of death among the old aged population is higher than from any other age category (AIHW, 2009).

Due to the aforementioned issue of falls, this essay is an inscription of a clinical audit proposal of local hospitals; fall prevention. It is in the audit proposal that various aspects of falls prevention worth addressing will be encompassed. Briefly discussed also will be that various stages employable in the auditing process. It is, however, worth noting that this is not an actual audit but rather a proposal where essential audit components and their significance will be brought into the limelight and discussed in the local health facility context.

In Australia, fall has been identified as the major causes of disabilities and injuries. Surveys have it that at least a single fall per year is experienced by 30% of adults aged sixty-five years and above. With the expected rise in the number of adults in the near future, this incidental fall rate is also expected to increase. Results from population study indicate that in 2010, the number was 3 million people which equates to 14% with the number expected to rise to 8.1 million people which is equivalent to 23% by 2051. Though at a stable incidental fall rate, the cost of fall management is expected to hike to 1.4 billion dollars come the year 2051.

The target of this clinical audit proposal is a local hospital based in Darwin. It is therefore crucial for the hospital’s management to have a value of its current cost of operation and how much it will cost in the near future. In 2017, it was estimated that the cost of a hip fracture is 139-209 million dollars. By 2051, the cost is however expected the rise to 321-482 million dollars. It is from these numbers that the severity of the issue can be sighted and subsequently points out the roles of individual organizations in reducing the number of falls and their long-term contribution towards achieving the national target of fall prevention. This clinical audit proposal is therefore developed to help ease the huge financial strain that faces the medical system.

Inclusion of regulatory or government requirements

In addition to financial constraints, there will be a deficit of beds required in health facilities. Whereas on the ministry of health in Australia the cost of the health system is continuously escalating, the physical cost of falls is not lagging behind. Information from the Australian Bureau of Statistics have it that falls are not the only leading agents that cause injuries amongst people aged 65 years and older. Falls, however, accounts for four percent of individuals that are admitted to hospitals from this age group. There is an exponential increase of hospital admissions as age increases. By basing on statistical data, the rate of hospital admissions emanating from falls is at a steady increase at a stable annual rate of 4.5% amongst males (Tovell, Harisson, and Pointer, 2017). The aforementioned rate is expected to double in 15.7 years. On the other hand, the rate for female individuals is at 7.9% annually.

For individuals aged 65 years and above, 40% of deaths related to injuries and 1% of the total deaths resulting from falls. Results from a study indicate that injuries due to falls are acquired by 22-60% of old people whereby 10-15% of these people acquire fatal injuries. 2-6% of them all suffer from fractures of hip fractures accounting for 0.2-1.5%. Other common injuries that are self-reported include sprains, bruises, and abrasions. Leg fractures, femoral neck fractures, fracture of radius-ulna amongst other bones of the arm and fractures of the trunk are examples of common injuries resulting from falls and warranting for hospitalization.

From the aforementioned, hip fracture is the most expensive in terms of treatment costs. The speed of recovery from hip fracture amongst older people is relatively slow with the vulnerability of such individuals to rest complications as well as post-operation complications being high. To bring a better picture of the dangers of falls, it is a fact that 25% of the older people suffering from hip fractures eventually die (Lukaszyk et al., 2017). Only 1/3 survives but are never able to get back to normalcy.

After falling, victims remain on the ground or floor for more than an hour. This is another consequence that is usually not commonly discussed. It is an implication of social isolation, weakness, and illness and usually results in a high mortality rate amongst the older people in the society. Subsequently, chances of muscle damage, pneumonia, hypothermia, dehydration, and pressure sores increases as the older person spends more time lying on the floor after a fall.

Involvement of stakeholders

This proposal recommends that five steps be followed during its implementation. Additionally, the proposal is also divided into five stages. They are; Identifying the problem in the chosen setting, reviewing the criteria and standards applicable in the selected setting, observing practice and collecting data, comparing actual performance with criteria and standards in actual practice, improving performance by basing on standards and criteria, and the implementable changes.

a). Determining the issue faced by the local hospital

- It is at this stage that the area deserving more attention than all the others is focused on.

Royal Darwin Hospital is the selected setting for fall prevention. Though there is already a strategy for falls prevention in existence, data dating 2017 December from the hospital indicates that there was an average of 1.7 falls per 1000 patient care days. Although the figure is far less than the national average of 3.2 falls in every one thousand patient care days, the cost of care implicated in the hospital’s budget has become a real burden.

In addition to the huge cost, employee and patient safety is another issue of concern. Falls should, therefore, be effectively managed with a target of having zero falls in a span of two years. Additionally, it is of great significance to be aware of the present falls’ status, the causes as well as the eminent dangers associable with the issue (Francis et al., 2017). From the hospital’s data, therefore, falls are the leading medical problem currently and requires urgent intervention.

b). the inclusion of regulatory or government requirements.

In the attempt to curb falls and the resultant deaths and injuries, the Australian Government has released guidelines to be implemented in hospitals, aged care facilities as well as residential care facilities. The guidelines are step by step processes that basing on validated methodologies, they aid in the implementation of the overall process. The guide is further divided into three main sections; Planning, implementing and evaluating. An implementation template has been included in the Appendix section and can be used in the actual implementation of a prevention stratagem for falls. The 10th standard of the National Safety and Quality Health Service should be assessed for the current settings.

c). Involvement of stakeholders.

It is of absolute necessity to identify and involve all stakeholders in the audit process. Internal, as well as external stakeholders, should be incorporated in the entire process. Internal stakeholders include patients and the hospital’s staff while external stakeholders include consultants and experts in the health industry. It is, therefore, a proposal of the audit to identify the number of stakeholders involved in the generation of fall prevention strategies. It is a requirement that there exists a balance between external and internal stakeholder representation (Stephenson et al., 2017).

Five steps of the clinical audit process

Members of the board and administrative staff must be included in the audit for its effectiveness. If need there be, external consultants sourcing from other local hospitals and in possession of prior experience in the fall prevention audit field must also be included in the entire process.

It is the proposal of this audit that one person from the healthcare profession and one person from the administrative department must work alongside the quality officer while conducting the audit. Personnel in the hospital must be, however, informed about the audit and all the people to be involved in the process. To avoid any negative implications on adherence to the plans of the auditing process, recommendations and suggestions from stakeholders must be taken into consideration. All sections such as employee union, health care professionals, the board of management and patient representatives must avail two.

members each who will form the monitoring and evaluating the team. Review meetings must be conducted before and after the team has been formed. It is also of great significance that team members are familiar with each other and any kind of conflict that could be existing amongst them solved before the onset of the monitoring and evaluation process. Team members must also maintain sufficient communication which could be achieved through the mail system, phone calls or any other specified online or offline mode of connection.

Upon undergoing through all the aforementioned system, stage 1 which is the foundation of the entire audit system will have been conducted to completion.

While setting standards and developing criteria, the initial step is going through the formed committee to identify existing local standards. in order to achieve an evidence-based implementation strategy, standards from the nearby local hospital must be considered. Standard 10 if the Australian Commission on Safety and Quality in Healthcare must be followed, discussed and evaluated in comparison with the hospital’s current standards.

There are four criteria that ought to be fulfilled according to the above standard, namely: prevention strategies that are currently in place, patients’ screening and nature of falls assessment during admission, stay, and at discharge, governance systems and structure for prevention of falls, and the lines of communication between the hospital and the patient and their relatives in relation to the imminent risks of fall and any prevention strategy that is in place.

The audit must also create room for comparing and contracting every standard outlined in the guidelines against the existing standards whether in practice or not in practice, reasons for practicing or not practicing, and the parties bearing the responsibilities for the aforementioned actions. It is, however, worth noting that this section does not focus on pointing out faults from employees but rather pinpointing existing gaps in the hospital setting that brings about the 1.7% annual fall rate (Giles et al., 2015).

Statistical data on falls and costs

Criteria setting

Upon identifying the criteria and standards for evaluation, next will be to identify the parameters of measuring the criteria and the consequences of the same in the fall prevention context. It is in this section that measurement statements that are in line with the standards and criteria must be included. The levels of performance and the results expected must also be included. It must also provide guidelines on what could be done whenever the expected performance is not achieved.

Target setting

Once the criteria have been set, indicators of progress and units of measurement must be outlined. The actual number of falls, for example, by patients in 1000 bed days monthly or per trimester must be deliberate. Setting of targets must also be based on the steps and criteria to be adopted. Additionally, the risk assessment tool to be implemented as well as subsequent protocols must be coined for assessment purposes within 24 hours after admission. In cases of existence of such a plan or strategy whatsoever; whether in use or not, has been in consideration for fall prevention in the future or not, and whether reported or not must be assessed (Francis et al., 2018). The target must incorporate baseline measures, data source and target measure which has been set in line with the standards and criteria to be followed.

This stage plays a significant role in clinical auditing as it offers a chance for the acquisition of real-time data on the practice of falls prevention. Any audit tool has been warranted in this stage. The auditing tool must, however, have the sections mentioned below for the purposes of documentation and recording.

- The collected data must be in accordance with the set criteria and objectives. For instance, if nursing is the set criteria, it is upon the nursing staff to report any factor that they identify as a cause of falls. In the data section, it must be indicated whether the nurses are taking appropriate risk factors reporting measures as well as whether the audit committee is identifying the risk factors being reported by the nurses within periods of fourteen days. This will, therefore, help in the determination of the real criteria status in the actual practice, awareness, and knowledge of health personnel in the facility.

-    The nature of the questions is to be quantitative. In the risk factors observation mentioned above, for example, the actual risk factors such as obstacles, loose cables, dim light collisions, slippery floor, and telephone cables should be mentioned. This will ease the analysis process and subsequently save time (Barker et al., 2016).

Impact of falls on elderly patients

-    Blank spaces must be left to give room for the writing of comments, suggestions, and recommendations from members of the auditing committee. Before any auditing tool has been formulated or implemented, the terms to be incorporated in the tool should be well defined.

-    The function of the tool must also be mentioned clearly. The chief intention of the audit is to determine the real standing of strategies aimed at fall prevention at national level being currently implemented ant the facility through;

Comparing the implemented standards and criteria with the number of falls from each ward.

Real-time practicing strategies, good documents maintenance, and regular synthesis and analysis of results through review meetings.

Conducting discussions at ward level to identify gaps in practice as well as the development, implementation, and evaluation of strategies against falls. The results obtained from the aforementioned should be properly documented and should be accessible at any time (Melin, 2018).

Clear instructions on how the audit tool should be filled should be provided by the audit. This should encompass sections for writing answers, ticking or circling the same. The time frame should also be mentioned. If the audit is to be conducted in ward sections, inpatient fall data should be availed from each ward.

Analyzing the data collected is the next step. Gathering of data collected in a database could be easily achieved with the help of a statistician. The statistician should then analyze the data and convert it into an understandable and relevant form. After analyzing the data, a conclusion should be sought from the information to determine the standard that has not yet been set, the risk factors associated with it and how its setting should be done.

As previously mentioned in stage two, an indicator of development that is measurable must exist. It is therefore in this section that a comparison of the target results with the current results will be done. When evaluating the knowledge of healthcare professionals on risk factors of fall, for example, possible target indicators could be 90% and above - Good, 80-89% - Moderate, 79% and below – Poor. If the current professionals indicate a Good knowledge level, efforts should be made to maintain the status at that. If the result6s are however found to be poor, the right course of action should be deliberated and implemented to enhance the same.

It is only after an expert panel and review meetings have discussed the results that the action section can be filled. Once the courses of actions have been identified, considerations must also be made on how they fir the existing criteria and standards. the barriers and limitations of implementing the standards must also be identified and reviewed before settling on an action plan that is most effective. It is at this stage that recommendations, suggestions, and conclusions from meetings of both internal and external stakeholders will be considered (Tzeng and Yin, 2015).

Cost of care for falls

The audit committee can design implementation plans for the enhancement of quality in the actual practice once data from all the preceding stages have been analyzed. To accompany the action plan, a control and monitoring plan should also be availed. These plans/sections are considered post audit but must be included in the proposal for actual implementation of the deliberated actions. Also included in the proposal is a pilot scale re-audit to monitor the progress upon implementation (Bruce et al., 2017).

If, for example, it is established that cables lying in the patient’s bedside are causing falls, instructing nurses to inspect the presence of any cable in the pathway upon entering and before leaving the patient’s room could be an effective action plan. Any cables found in walkable pathways should be removed and laid elsewhere with the ward manager as well as the quality manager being notified with immediate effect.

Through proper documentation, the number of falls can be effectively calculated or even correlated with the causal risk factor to determine an average number falls and rule out an increase or decrease of the falls. Upon getting the results, a comparison with the set targets can be made and subsequently implement the most effective action plan. Poor on professional’s knowledge of risk factors could be curbed through the erection of posters or LED displays in patients’ sections. 15 days after implementation of the plan, the progress must be checked again using the audit tool. Subsequently, the effectiveness of every intervention plan and its target score can be determined (Morris and Oriordan, 2017).

Since multiple professionals and departments are involved in the audit process, conflicting points of view are bound to occur. If the conflicts are tamed to reasonable levels, they are usually of benefit to the audit as a combination and critique of ideas yields better results than one idea. Categorical grouping of identified barriers should be done based on whether the barriers are employee caused, patient caused, inherent, anonymous or system caused. Upon identification of the barriers, their effects should be evaluated and possible remedies identified to prevent their re-occurrence in the future.

Basing on this audit proposal, the ideas inscribed here can be confidently put in actual action for future audits. The resultant audit should be understandable, simple, easy to use and proper analysis is done. It is worth noting that conducting complex audits could bring about results full of errors which could have lethal implications in actual practice. Since health care professionals such as nurses, dentists, and other physicians are busy in their daily undertakings, suitable time should be set aside for conducting the audit. Though communications about the processes to be involved in should be communicated to all participants, real-time observation and collection of data should be in unbiased ways.

Implementation of fall prevention strategies

This implies that healthcare professionals should not be aware of the actual time that observations will be conducted as they are bound to act differently and subsequently alter the actual results. Another key aspect of a successful audit is the incorporation of all relevant stakeholders in the entire process. Each group of stakeholders must have a representative from within their workforce to represent their interests in the audit committee. All the stakeholders must be working towards falls prevention with no cases of diverted attention.

It is worth noting that Audit is a qualitative approach to establish the measurable and rectifiable causal factors rather than finding out the mechanism behind the effects emanating from the problem at hand. It is therefore of much importance that the data collection process be oriented towards achieving pre-set targets and objectives. Knowledge emanating from the audit process is to be shared with the loopholes identified being shut down. In conclusion, this proposal is just the starting point towards admirable fall prevention performance and not the end.

References

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