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  Joint Commission Center for Transforming Healthcare Aims to Prevent Inpatient Falls with Injury  
A Robust Approach Leads to Significant Reduction of Inpatient Falls with Injury
(OAKBROOK TERRACE, Ill. – April 28, 2014) Approximately 11,000 fatal patient falls occur in U.S. hospitals annually, but hospitals using new measurement systems and solutions from the Joint Commission Center for Transforming Healthcare Preventing Falls with Injury project were able to reduce the rate of patient falls by 35 percent and the rate of patients injured in a fall by 62 percent.

Between 30 to 35 percent of patients that fall sustain an injury. On average, these injuries result in an additional 6.3 days in the hospital. If the Center’s approach is translated to a typical 200-bed hospital, the number of patients injured in a fall could be reduced from 117 to 45, and save approximately $1 million annually through fall prevention efforts. Similarly, a 400-bed hospital could reduce the number of patient falls with injury by 133 and expect to save $1.9 million annually.

The organizations that volunteered for the Center’s project to address preventing falls with injuries were:

The participating hospitals ranged from a 178-bed community hospital to a 1,700-bed academic medical center. All of the organizations used Robust Process Improvement® (RPI®), to identify causes and develop solutions to prevent patient falls. RPI is a fact-based, systematic, and data-driven problem-solving methodology that incorporates tools and concepts from Lean, Six Sigma and change management.

Working with the Center, the participating hospitals were able to significantly reduce the total number of falls and falls with injury by creating awareness among staff,   empowering patients to take an active role in their own safety, utilizing a validated fall risk assessment tool, engaging patients and their families in the fall safety program, providing hourly rounding that includes proactive toileting, and engaging all hospital staff to ensure no patient walks by himself.  These examples are some of the targeted solutions developed to address contributing factors around why patients fall. 

The targeted solutions, which were thoroughly tested and proven effective during the project, are strategies developed to mitigate contributing factors. In all, the hospitals and the Center created a total of 21 targeted solutions during the course of the project. As solutions were developed, the hospitals discovered that fall prevention was not a set of disparate and unrelated activities.  Instead, preventing falls was a key strategy in preventing or minimizing patient harm.

“Patient falls are a serious problem that have received a great deal of attention, yet defy easy solutions,” says Erin DuPree, M.D., vice president and chief medical officer, Joint Commission Center for Transforming Healthcare. “These seven organizations are leading the way in developing strategies that keep patients safer. By using these approaches to determine the specific causes of falls and targeting interventions accordingly, real and substantial improvement can be achieved.”

The Targeted Solutions Tool® (TST®) for preventing falls with injury is currently in development for release in 2015. The TST is an online resource that provides a step-by-step process to assist organizations in measuring performance, identifying barriers to excellent performance, and implementing the Center’s proven solutions that are customized to address specific barriers. TST modules are now available for improving hand hygiene, hand-off communications, and wrong site surgery. Accredited organizations can access the TST free of charge on their secure Joint Commission Connect extranet.

The Center is grateful for the generous leadership and support of the American Hospital Association, BD, Blue Cross and Blue Shield Association, Cardinal Health, Ecolab, GE Healthcare, GlaxoSmithKline (GSK), Johnson & Johnson and Medline Industries, as well as the support of GOJO Industries, Inc; The ARAMARK Charitable Fund and Federation of American Hospitals.

For more information about the Joint Commission Center for Transforming Healthcare, visit 

Statements from the Preventing Falls with Injury participating organizations
“The Six Sigma process confirmed that fall prevention is a complex and challenging patient safety issue. The extensive data analysis of this project reinforced how important it is to know the root causes for a specific population of patients. While most interventions can be standardized, some must be adjusted throughout the patient's stay due to changes in their condition. The nurse must think beyond fall risk assessment and implement interventions that match the patient's need."
Eileen Constantineau, practice specialist, senior coordinator, Barnes-Jewish Hospital, St. Louis, Missouri
“Kaiser Permanente San Diego Medical Center found partnering with the Joint Commission Center for Transforming Healthcare a very valuable experience in contributing to significant improvements in patient safety. The experience provided a structured framework around which to build our work around preventing patient falls and patient falls with injury.  In addition, the sharing of strategies and best practices with other organizations has been invaluable. This collaborative is an outstanding example of health care organizations truly collaborating to move forward the work of keeping our patients safe.”
Sally Franz, director, Medical/Surgical/Critical Care Nursing, Kaiser Permanente San Diego Medical Center

“Wentworth Douglass Hospital was honored to participate in this collaborative with other high performing organizations.  The collaborative provided a unique opportunity to share data, challenges and interventions.”
Peggy Gagne, M.S.N., RN, nursing administration project manager, Wentworth-Douglass Hospital, Dover, New Hampshire

“Memorial Hermann Memorial City Medical Center was truly honored to partner with both the Joint Commission Center for Transforming Healthcare and the six other participating facilities. Through this initiative our group was able to collaborate by sharing ideas and solutions to develop best practices to reduce patient falls with injuries.”
Maryellen McGlothlin, RN, BSN, NE-BC; Memorial Hermann Memorial City Medical Center, Houston, Texas
“Working with other high performing organizations on this Robust Process Improvement® initiative gave us the opportunity to develop and test truly innovative solutions.  Additionally, we were able to revisit evidence-based methods for falls reduction and come up with new methods for implementation at our institution. Working together allowed us to leverage our collaborative strengths and experience.”
Susan Reeves, PT, DPT, NCS, clinical director, Physical and Occupational Therapy, Wake Forest Baptist Medical Center (project co-leader), Winston-Salem, North Carolina
“Working with various systems on this collaborative was the catalyst for developing interventions to improve patient care and safety that can be implemented regardless of hospital size, resources available, etc. The relationships built during the collaborative reach far beyond the timeline of the defined project to continually share challenges and innovative ideas for improvement.”
Christopher Shutts, director, STEPPS Program, Baylor Scott & White Health, Dallas, Texas


About the Joint Commission Center for Transforming Healthcare

Created in 2008 as a non-profit affiliate of The Joint Commission, the Joint Commission Center for Transforming Healthcare aims to solve health care’s most critical safety and quality problems. The Center’s participants – some of the nation’s leading hospitals and health systems – use a systematic approach to analyze specific breakdowns in care and discover their underlying causes to develop targeted solutions that solve these complex problems. In keeping with its objective to transform health care into a high reliability industry, The Joint Commission shares these proven effective solutions with the more than 20,000 health care organizations it accredits and certifies. Hospitals have made significant advances in quality – even better results are now achievable. Hospitals and The Joint Commission are working together to improve systems and processes of care. Learn more about the Center at



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Read the “Journal of Nursing Care Quality” article on the project

More about the Preventing Falls with Injury project

About the Joint Commission Center for Transforming Healthcare

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Elizabeth Eaken Zhani
Media Relations Manager
The Joint Commission

Katie Looze
Media Relations Specialist
The Joint Commission