(Solved) Executive Summary: Quality Improvement Initiative

(Solved) Executive Summary: Quality Improvement Initiative

In this assignment, you will select a program, quality improvement initiative, or other project from your place of employment. Assume you are presenting this program to the board for approval of funding. Write an executive summary (850-1,000 words) to present to the board, from which they will make their decision to fund your program or project. The summary should include:

The purpose of the program or project.
The target population or audience.
The benefits of the program or project
The cost or budget justification.
The basis upon which the program or project will be evaluated.

Please use reference:
Huber, D. (2014). Leadership and nursing care management (5th ed.). Maryland Heights, MO: Saunders Elsevier. ISBN-13:9781455740710.



Patient Fall Management Program

The purpose of the program or project

The purpose of the program is to considerably minimize the number of patient falls in the health facility. Minimizing patient falls remain a major health care goal. As reported by Pati et al. (2018), patient falls with serious injuries consistently remain among the top 10 sentinel events. The Agency for Healthcare Research and quality estimates that between 700,000 to 1,000,000 people fall yearly when in hospital. Falls commonly have serious consequences, especially for older residents. Any injuries related to patient falls to reduce the quality of health of the patient and also increases the cost of healthcare. Again, residents who fall but do not acquire any injury acquire the fear of falling which limits their mobility. Injuries from falls also lead to lawsuits against staff or health facility and can at times be costly.

Thus, this program seeks to impose a long term approach to managing patient falls. The approach is to comprehensively conduct a[cmppp_restricted] fall assessment on all residents at admission and develop an individualized intervention plan. Different residents have different health problems and as such should be managed and monitored based on their condition and risk of fall. One of the major challenges of fall prevention is that some of the prevention care offered to avoid falls are routinized (Taylor et al., 2005). Again, fall prevention activities have to be balanced with other considerations such as providing the best care and minimizing restraints. However, having an individualized plan for every resident at risk of falling will ensure that patient-centered care is offered. The residents should be monitored regularly, and the plan revised accordingly.

The target population or audience.

This program target the acute care department. Residents in the cute care departments have a high risk of falling due to their conditions. Staff in acute care departments have a conflicting set of goals in that they have to treat the residents for the health conditions that prompted the admission, help them recover or maintain mental or physical function and keep them safe. This requires a highly personalized plan that will ensure both the staff and the patient are safe. The program will concentrate much on retraining the staff on how to asses and record risks of falling and subsequently monitor and revise the plan. Again, the facility has to employ more staff on either permanent or part time basis to ensure the program has enough staff to personalize care.

The benefits of the program or project

This program has many benefits with the major benefit being offering patient-centered and high quality care. Patient falls to reduce the quality of health care due to injuries, fear of falling leading to self-imposed limitations and other problems. Again, patient falls also increases the cost of healthcare in that some injuries are serious and increases the residents stay at the hospital. Thus, the program seeks to minimize patient falls to not only reduce the cost of healthcare to patients and health facility but also to improve on the quality of healthcare offered in the facility. Minimizing the risk of patient falls. Reducing the risk of patient falls is one of the International Patient Safety Goals (IPSG) set by the Joint Commission (2017), and all hospitals are expected to work towards achieving this goal.

The cost or budget justification

The program requires hiring more medical staff as well as offering regular training on different aspects such as communication and effective risk assessment. This requires an increase in the cost at the facility in the short term but will eventually lead to a reduction in costs. First, a study by Morello et al. (2015) showed that patient falls that led to an injury increased the patient length of stay by 4 days on average and increased cost by $4727. Again, since 2008, CMS does not reimburse facilities for certain in-hospital injuries most of which can occur after a fall. There is also the costs accrued from lawsuits filed by patients after falls. All these contribute to the high operational costs at the facility. However, by reducing patient falls, these costs will be reduced drastically and in the long term lead to lower operational costs.

The basis upon which the program or project will be evaluated.

The program will be evaluated based on a number of patient falls. The goal is to minimize the patient falls. The number of falls will be recorded and on a monthly basis and then reviewed. A quarterly departmental review will also be conducted to identify areas for improvement. Success will be measured based on the number of monthly falls relative to the previous figures before the program. However, in the long term success will be measured by the reduced number of falls as well as reduced costs to the facility as well as improvement in offering quality healthcare. This is to ensure that preventing falls does not interfere with other aspects of healthcare offered in the acute care department.



Huber, D. (2014). Leadership and nursing care management (5th ed.). Maryland Heights, MO: SaundersElsevier. ISBN-13:9781455740710.

Joint Commission. (2017). Joint Commission International accreditation standards for hospitals (6th ed.). Oakbrook Terrace, IL: Joint Commission Resources.

Morello, R. T., Barker, A. L., Watts, J. J., Haines, T., Zavarsek, S. S., Hill, K. D., … & Stoelwinder, J. U. (2015). The extra resource burden of in‐hospital falls: a cost of falls study. Medical journal of Australia203(9), 367-367.

Pati, D., Lee, J., Mihandoust, S., Kazem-Zadeh, M., & Oh, Y. (2018). Top five physical design factors contributing to fall initiation. HERD: Health Environments Research & Design Journal11(4), 50-64.

Taylor, J. A., Parmelee, P., Brown, H., & Ouslander, J. G. (2005). The falls management program: A quality improvement initiative for nursing facilities. Book The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities (Editor ed.^ eds.). [/cmppp_restricted]