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Virtual Breakthrough Series, Part 2: Improving Fall Prevention Practices in the Veterans Health Administration.

Lisa Zubkoff¹, Julia Neily², Pat Quigley³

¹Health Science Specialist, White River Junction Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont; Assistant Professor of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

Joint Commission Journal on Quality and Patient Safety

|March 8, 2017

Summary

This summary is machine-generated.

The Veterans Health Administration's Virtual Breakthrough Series collaborative reduced major fall-related injuries in participating units by implementing new strategies. This initiative shows promise for preventing patient harm from falls.

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Area of Science:

Healthcare Improvement
Patient Safety
Quality Management

Background:

The Veterans Health Administration (VHA) initiated a Virtual Breakthrough Series (VBTS) collaborative to address falls and related injuries.
The VBTS aimed to enhance fall prevention program infrastructure, strategies, and evaluation.

Purpose of the Study:

To evaluate the effectiveness of the VBTS collaborative in reducing falls and fall-related injuries within the VHA.
To assess the implementation of fall prevention interventions and program changes by participating teams.

Main Methods:

The VBTS involved a structured collaborative process with prework, action phases, and continuous improvement.
Key actions included educational calls, monthly reporting, coaching, and feedback.
Evaluation encompassed intervention assessment, team capacity, infrastructure changes, and fall/injury rates.

Main Results:

Fifty-nine teams participated, with most submitting monthly reports and implementing an average of 6.66 interventions.
Frequently adopted interventions included staff education, post-fall huddles, data tracking, and improved communication.
A statistically significant decrease in major fall-related injury rates was observed for participants (6.8 to 4.8 per 100,000 bed-days).

Conclusions:

VHA teams successfully implemented changes through the VBTS collaborative, leading to reduced major fall-related injuries.
The study demonstrated the promise of these approaches in mitigating inpatient fall-related harm.
Participating teams enhanced their fall prevention programs through data analysis and injury reduction strategies.