November 12, 2007

Stop Falls or Risk Payment Denials
By Patrice L. Spath, BA, RHIT
For The Record
Vol. 19 No. 23 P. 18

With the announcement that Medicare will not pay for preventable conditions acquired at hospitals, stopping patient falls has even greater significance.

Healthcare quality entered a new era when the Medicare changes to the 2008 hospital inpatient payment rates were released in August. Beginning with discharges occurring on or after October 1, 2008, hospitals will not receive additional payments to cover the costs of managing patients who develop certain hospital-acquired complications or conditions: an object inadvertently left in a patient during surgery, a transfusion reaction due to blood incompatibility, an air embolism, mediastinitis following coronary artery bypass surgery, urinary tract infections associated with catheter use, pressure ulcers on infections associated with the use of intravenous catheters, and hospital-acquired injuries.

Under this no-pay policy, coders will need to determine whether any noncovered conditions were present on admission (POA). The biggest challenge will be making sure that physicians have adequately documented the POA status. Lack of physician documentation could result in the coder reporting the condition as not being POA, which can influence the hospital’s reimbursement.

While HIM professionals may view the coding and documentation issues as daunting, these challenges pale in comparison to the efforts needed to prevent the occurrence of iatrogenic or hospital-acquired events. Reducing patient falls, one of the more common hospital occurrences, can reduce the risk for spatient injuries—an event that is on Medicare’s no-pay list. The incidence of falls in hospitalized patients is not well-known because these mishaps—especially those not causing patient injury—may not be routinely reported. However, recent studies of fall incidence during hospitalization report an average fall rate of up to 3.6 per 1,000 patient days. The actual number is probably even higher than the study suggests.

In the past, hospitals’ fall prevention strategies were mostly reactive, the focus being on analyzing falls that cause significant patient injury. A root cause analysis was done to determine the causal factors of and underlying reasons for a particular sequence of events and actions taken to reduce the chance that something similar would happen. With the looming threat of nonpayment for injurious events, hospitals must switch to a proactive mode. This involves inquiry into the common causes of all falls—not just those that result in patient injury—and implementation of prevention strategies.

Establish Fall Risk Factors
The first step toward reducing falls in hospitalized patients is to conduct a comprehensive analysis of the current nature and scope of falls occurring on different nursing units. Many facilities require an incident report be completed for patient falls. Although this report may not be routinely completed, it is a starting point for gathering information for the falls analysis.

Quite likely, patient records will also need to be reviewed, as many incident reports lack critical patient characteristic information such as level of activity at the time of the fall, presence of orthostasis, incontinence, current medications, etc. By reviewing patient records, more information can be gathered about fall location, severity, time of day, frequency, and characteristics of patients prone to falling. Analysis of data of this depth and scope enables clinicians, administrators, and quality managers to profile the level of fall risk among patients, along with the actual factors contributing to falls. This detailed information allows for the development of an interdisciplinary fall prevention program customized to the needs of different patient populations.

A frequent question is, “Why not start by implementing evidence-based fall prevention strategies and forgo this preliminary data analysis?” There are plenty of resources detailing how to prevent falls in hospitalized patients, two of which are listed at the end of this article. However, the value of a preliminary, in-depth data analysis of the hospital’s own patient fall experiences is twofold. First, the information creates an improvement imperative for caregivers. When caregivers understand how often patient falls are actually happening in their own hospital, they are more likely to embrace the need for prevention strategies—some of which will require more work for staff members.

The data are also important for a second purpose: The improvement team charged with improving fall prevention practices will be better able to target interventions in the most problematic areas.

Undertake an Improvement Project
The first step is to form an interdisciplinary improvement team to tackle the problem of patient falls. Ideally, the team includes representatives from the nursing staff, unit assistants, patient transportation, pharmacy, and rehabilitation. Have team members review data on the facility’s patient fall experiences and various fall prevention recommendations from the literature. Ultimately, the team should identify the key steps that need to be taken to achieve a reduction in patient falls. Once the steps are identified, the team can conduct a proactive risk assessment. To illustrate how this can be accomplished, suppose the team identifies the following steps as being critical to preventing patient falls:

• Conduct an initial patient assessment using the Morse Fall Risk Assessment tool.

• Record the total fall risk score on the patient’s interdisciplinary care plan.

• Implement a high-risk fall prevention plan for patients with a Morse Fall Risk score of 50 or higher or if the nurse judges the patient to be at higher-than-normal risk for falling.

• Communicate the patient’s fall risk to other disciplines.

• Monitor a high-risk patient according to policy/procedure and reassess the fall risk as indicated.

• Educate the patient and family.

The failure mode and effects analysis (FMEA), a prospective risk analysis technique involving a close examination of a process to determine where improvements are needed to reduce the likelihood of unintended adverse events, is the improvement model the team should use. The first part of the team’s completed FMEA is shown in Figure 1. For each step believed to be critical in preventing patient falls, the team determines the following:

• What could go wrong?

• If something does go wrong, how would this affect the likelihood of a patient fall?

• What needs to be done to prevent these failures?

The team answers these questions by performing a hazard analysis, which involves brainstorming all possible failures that may occur at each step and the resulting outcome if such failures do occur. The results of this discussion are shown in columns 2 and 3 of Figure 1. After completing this step, the team picks the most critical failures—those most likely to happen and with the greatest risk of a poor outcome. The data collected during the comprehensive analysis of the current nature and scope of falls in the hospital are particularly useful during this step of the FMEA project. Instead of using hunches or guesses to pick critical failures, the team has data to guide its choices.

The team uses a score system (shown at the bottom of Figure 1) to rank the severity of the effect (the outcome if the failure occurs), the probability that the failure will occur, and the likelihood that the failure will be detected and corrected before an undesired outcome occurs. These scores are multiplied (severity X probability X detectability) to calculate a criticality score for each failure (shown in the last column).

At this point in the project, team members can easily become overwhelmed by the realization that there are many potential failures that may cause a patient to fall. The ideal is for every patient care process to be 100% fail-safe. However, this goal is often unrealistic given the finite resources available to control risks and the propensity of people to make an occasional unintended mistake. The team uses the criticality scoring system to determine which failures are most important to prevent. What the team discovers is that all process failures are not equally consequential. There are no absolute rules for defining a critical failure. The following are some guidelines to consider when selecting critical failures that warrant further action:

• high severity score (potentially serious failure);

• high severity X probability score; or

• high criticality score (severity X probability X detection).

Improve Fall Prevention
For this FMEA project, the team selects what it believes to be three critical failures: all shifts and disciplines do not implement interventions consistently, inadequate communication among disciplines, and patients not being monitored as required by policy/procedure (see Figure 2). Before the team can determine the best way to prevent these failures, the root causes of these failures (column 2) must be identified. Traditional reactive root cause analysis investigation methods are used to determine the underlying cause of each critical failure so appropriate actions can be taken.

Quality improvement tools such as cause and effect diagrams and detailed process flow charts can sometimes be useful during this phase. The team solicits input from other caregivers involved with preventing patient falls to provide more insight into the cause of critical failures. Finding the underlying cause of critical failures is an important step toward developing appropriate action plans—that’s why the team doesn’t rush through this step.

Once the root causes of critical failures are identified, it’s time for the team to recommend actions. The goal of these actions is to reduce the severity, frequency, and/or detection ratings of each critical failure. Before developing actions, the FMEA project team again reviews current literature recommendations for preventing falls in hospitalized patients. Knowing how other hospitals have solved similar problems is often an important learning experience. The actions recommended by the team are shown in the last column in Figure 2.

Monitor Success
After making changes, it is important to determine whether the rates of patient and injurious falls actually declined. The data should be unit-specific and population-based to uncover any contributing factors not originally considered by the FMEA team. When analyzing the effectiveness of fall prevention programs, rates of both fall incidence and severity of injury should be included. To analyze fall rates at the unit-level, the following formula is recommended: Number of Patient Falls ÷ Number of Patient Bed Days X 1,000.

This formula accounts for changes in patient census so that fall rates can be adjusted for census and then compared across units.

Because an elevated fall rate may be due to one patient falling several times, it is important to include a subanalysis of the data to determine what percent of the falls are second, third, or fourth falls or more. These repeat fall frequencies are needed to determine the effectiveness of interventions to prevent repeat falls. The fall injury rate, as illustrated in the following formula, reports how many injuries occurred per 100 falls. The multiplier is changed to 100 to produce a meaningful rate for such a rare outcome: Number of Injuries ÷ Number of Falls X 100.

Further classifying fall injuries based on severity will provide more information. For example, a unit may have had eight patient falls in the last month. Of those, one resulted in a minor injury such as an abrasion, a hematoma not requiring medical attention; one resulted in a major injury, such as a hip fracture. The remaining six resulted in no injuries. If one unit exceeds other units’ monthly fall and injury rates, it should be targeted for evaluation and intervention. In addition to tracking fall injury and injury severity rates, the organization can monitor the number of days between major fall injuries. Increases in the length of time between major injuries are another way to evaluate effectiveness.

What is an acceptable rate of reduction? From a patient safety and reimbursement standpoint, the goal should be zero harmful falls, but is this realistic? Healthcare quality professionals predict that patient falls will probably be the most difficult of the eight Medicare no-pay conditions to prevent. Hospital caregivers can accurately identify patients at risk for falls and take appropriate precautions, but patients may not always follow instructions. Short of having 24-hour sitters in every patient’s room, there may be no way to prevent an occasional stumble—and some will cause an injury. But this reality does not change the fact that injuries related to patient falls will not be counted as a complication that increases Medicare reimbursement. Whether this will have a significant effect on payment has yet to be determined, as many hospitalized patients already have a complication or comorbidity that results in assignment of the case to a higher paying diagnosis-related group.

Preventing patient falls demands a systematic approach, consisting of identifying internal and external factors that place patients at risk, attempting to reduce risk through medical, rehabilitative, nursing, and environmental strategies, and utilizing early warning systems such as bed alarms and fall prevention bracelets.

— Patrice L. Spath, BA, RHIT, is a healthcare quality specialist, author of Patient Safety Improvement Guidebook, a partner in Brown-Spath & Associates (www.brownspath.com), an assistant professor in the department of health services administration at the University of Alabama in Birmingham, and a contributing editor at For The Record. She may be reached at Patrice@brownspath.com.

Resources
Agostini JV, Baker DI, Bogardus ST. Prevention of falls in hospitalized and institutionalized older people. In: Markowitz AJ (ed). Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, Md.: Agency for Healthcare Research and Quality; 2001:281-299. Publication 01-E058.

Department of Veterans Affairs, Veterans Health Administration National Center for Patient Safety. Falls Toolkit. 2004. Available here.