NURS2006 Clinical Governance and Practice Improvement

To reduce the rate of fall related injuries among the community dwelling older adults by preparing a thorough exercise regimen. This project would focus on reducing the falls up to 20% in the ward of X clinical settings.

In order to reduce the rate of falls an exercise program has to taken up in the X clinical setting. The patients will be imparted with education regarding the usefulness of the exercise and each patient will be entrusted with specific exercises by the physiotherapists. The outcome will be evaluated by a follow up of six months.

Falls and fall related injuries in adults are mainly caused due to the age, poor physical condition, and lower functional status (Desure et al. 2013). Fall related injuries in elderly person decreases their quality of life by lessening their confidence.  Often older adults feel that in most of the cases, the cause of the falls can be avoidable. According to Cadore et al.(2013), proper exercise regimens have been found to decrease falls among the elderly people. Hence this paper aims to focus that exercises can help to retain balance among the older adults.

Relevance of Clinical Governance to your project

Clinical Governance is the systematic approach to provide the quality of care to the client by reducing the risks and complication.  Clinical risk management involves improvement in the quality and the safety of health (Heyrani et al.2012). This can be accomplished by detecting the circumstances that put the patients at risk and then acting accordingly to mitigate that harm. In this project the risk has been identified as fall among the elderly patients due to lack of balance, cognitive disability and medication effect (Khoury et al.2013). The strategy in this case is effective exercise. The staffs are responsible for their own actions and ensure client safety at highest level (Granacher et al.2013).  In this project an attempt has been made to reduce the fall rate in the community. Therefore, the third pillar of clinical governance, which is risk management, is used to analyse the risk factor and implement effective intervention to overcome the situation. The incident of fall has been increasing due to diminish physical functioning and physical inactivity (Iwamoto et al.2009). As exercise is the most effective way to improve the body balance and prevent falls in elders in the community. (MS Kaminska et al 2015, p.3407).Exercise is a part of health care and it gives an opportunity to have social interaction.(Shier.V et al.2016,p.3) . It has been found that exercises that challenge balancing are far more effective in preventing falls, than those that do not challenge the balancing program. It has been found that the older adults should practice how to control the movements of their body's centre of mass (Heyrani et al. 2012). It is always not about fall related injuries, proper balancing exercises can reduce the risk of some cardiovascular diseases and many chronic diseases (Gillespie et al.2013). The ACHM and the (American heart association) AHA recommends regular exercises for the adults aged 65 years and over. According to recent cochrane review, risks and all rates can be decreased by 15% to 32% depending on the type of targeted exercise (Horne et al.2013).

Evidence that the issue / problem is worth solving:

The following graph depicts that fall related deaths occurs among the older adults above the age of 65. Extensive search through literature have found that even a little bit of exercise can help in prevention of falls among the older adults (Giné-Garriga et al. 2014). According to the epidemiogical statistics about 30% of community dwelling elders over 65 aged and 50 % over 80 year, fall annually. Fall is the sing cause if disability and mortality. The admission rate of fall related injuries in Australia were over 60 in Australia as  2,000,000 non fatal injuries are treated in hospitals in 2013 (Hempel et al. 2013).The cost burden is increasing on health care sector. (Kaminska.MS et al, 2015, p.3407). According to Gillespie et al. (2012), fitness aerobic exercises, balance exercises can be useful for the elderly people. After the age of 40 the strengths of the lower limb muscle decreases, which has been considered as one of the driving factors for falls (Granacher et al.2014). Hence, power exercises, balancing exercises, toe stands, knee curls. Leg extension exercises can be useful for making the thigh muscles, leg muscles and lower back muscles stronger (Desure et al. 2013). All these evidences prove that an exercise program is strongly needed in the X- hospital to reduce the rate of falls and the decrease the chance of sentinel events due to falls.

Key Stakeholders:

The stake holders that play an important part of this project are the patients, the doctors, the nurses and the physiotherapists.

Physiotherapists- They will review and device the treatment program by using manual therapies and therapeutic exercises. They are the one to assign particular exercises to specific patients (Moyer 2012). 

Patients- They will be giving the feedbacks regarding the interventions.

Nurses- Play the leading role in carrying out the interventions related to falls. A nurse should be able to use the standard assessment tools for detecting the level of risks apart from the exercises; Some of the common preventive measures that can be taken by the nurses are hourly rounds, communication with the patient and medication review (Milisen et al.2012).

Doctors- The doctors will monitor if there is any adverse effect during or after the completion of the exercise regimen.

CPI Tool:

Clinical practice Improvement is the means of improving and managing the quality of care provided to the patient. It helps to evaluate the measure that has been taken to ensure a safe and quality care (Taylor et al.2013). The CPI method is mainly dependent upon the following questions such as ' What are we trying to accomplish?', How will one know that the setting requires a change?', 'what changes has to be made that will bring about an improvement in the given problems?'. It is necessary to have CPI training for learning the skills of comprehensive identifying, planning and identifying the issue.

There are is a couple of CPI tools among which the PDSA model (Plan- Do- Study- Act) are normally used in the quality improvement strategies aimed at bringing out positive changes in a health care setting. This model follows a cyclical pattern of impacting and assessing the changes (Taylor et al.2013).  The PDSA cycle is normally used to evaluate changes in the system by designing a plan, and then carrying out the plan followed by the subsequent understanding and follow up of the plan (Terroso et al.2013).  It is necessary to answer 3 questions before using the PDSA cycle in this project, The goal of this project, evaluation of the reached goals, interventions for reaching the goals. 

 The goal of this project is to reduce the rate of falls among the older adults in the X hospital ward.  There will exercise programs for the elderly patients of the ward under the supervision of the doctors, physiotherapists and the nurses (winter et al.2013). The outcome of the implemented plan have been assessed and studied. A record plan is kept to jot down the names of the respondents who have participated in the drills and the exercises (Gillespie et al.2013).  Finally a feedback is taken from both the parties receiving the benefits that are the patients and the parties giving the benefits such as the physiotherapist and the nurses. All the records and the documentations of the feedback were evaluated for implementing routine exercise plan for the fall prone persons in the hospital ward.

One of the proposed interventions to prevent falls and fall related injuries in older adults is by carrying out physical exercises regularly. More or less all falls are related to lack of physical fitness. The PDSA tool used above can be elaborated as follows:-

PDSA tool

Tool: Patients feedback

Step: Exercise program for the elderly patients in the hospital ward, for preventing falls.

Cycle- 1st try

Plan: -In the planning phase-a proposal will be written to the finance department and Director of health care sectors and community welfare organisation, requesting funds for project budget. The copy will be sent in 4 December 2015.

A meeting will be held for discussing the topic with the community welfare agency or organisation to approve the project. We plan to put up an exercise program in the ward of the X hospital. We also plan to record the outcomes for implementing positive changes in the hospital settings.

 Do- The exercises programme will be held in the X class settings and will be conducted under supervision.

· The primary care instructor may help in recruitment and promote adherence to the exercise regimen.

· The adherence can be promoted by phone calls, regular session and home visits.

· The nurse might assist clients in exercise and seek advice from physician.

·  The physiotherapist is the instructor, will prescribe exercise individually during 5 visits over six month. The family members can also take part in this group to support their elders.

· The exercise will be held for 30 minutes, three times per week. The programme include muscle stretching, walking and balance retraining .The client aged between 65 -75 will be invited by primary care worker to participate. The arising health issues by exercises will be handling by Physiotherapist and nurse.

Study- It is necessary to study whether the exercise plans worked well or not, whether the exercises have to be continued or stopped. The doctor will monitor the outcomes of each participants of the exercise regimen on the basis of prescribed exercise. If there are any adverse effects, then the doctor will try to mitigate that effect. The nurses will document the feedback from each patient for further evaluation. It will help in keeping a record of the patients who did not take part in the program.

Act- A record sheet be kept that shows name of the participants, who have attended the programme. It will also include the exercise performance and timing of exercise held. The effectiveness and outcome of the exercise should be mentioned in record sheet. It is necessary that the patients be approached often, reminding about their exercises as, once a patient steps out of a building, and he would likely not follow the rules.

Barriers to implementation and sustaining change:

Studies have shown that the reason of non adherence to exercise programme are as follows:-

· Elderly persons tend to forget easily-They are likely to forget the rules and the norms as soon as they get away from any clinical setting.  In a clinical setting, they remain under the continuous surveillance of the doctors and the nurses and everything has to be done in time as, a continuous documentation followed, so normally omissions does not occur (Loganathan et al. 2015).

· The cost of transport to reach in programme- In many cases, the elderly persons have to financially depend on their children. In some cases an elderly person might not get that much support from their family, such that they cannot afford the costs of reaching the program venue.

· The attitude and judgement of elders- Elderly people are often judgemental and are often against any new changes, be it a positive change or a negative ones.  Hence it sometimes becomes very difficult to convince them or make them understand the beneficial effect s of a particular thing (Milisen et al. 2013).

· Very frail elderly are worried to participate- some patients who are very frail and week cannot be brought under any exercise schedule. They and the patient are often worried to participate in this sort of exercise programs as they might think that this could deteriorate their health status (Loganathan et al. 2015). A study should not be preceded without the consent of the patients and his family hence it is advisable not to include the unwilling patients.

· Improper conduct of the health care professionals and the clinical staffs- It is not that all clinical staffs and the therapists have to be excellent in their codes of conduct.  A nurse or a clinical staffs might not deliver proper education to the patient or may not help the older patients in carrying out necessary exercise.

Evaluation of the project:

A conclusion can only be made after the feedback from the patients. Positive outcomes would help to continue the exercise programs and the negative outcomes will be evaluated for further improvement. A pre and a post study of the intervention should be useful in evaluating the success of the project.

For the evaluation, the past 6 months data has to be collected. Feedback sheets can be provide to the patients containing a list of questionnaire such as :- 

· Why do you think exercise is necessary to prevent falls?

· Did you notice any desirable changes after exercise programs?

· Has there been any improvement?

· Did the staffs explain all the good and the bad points of an exercise before the commencement of the exercise regimen?

· Were the education and the training helpful to you?

· Were the clinical staffs cooperative?

· Did they remind you of your exercise in the past six months? 

Feedback can also be taken from the doctors, who will assess the patients after the exercise program, regarding their improvement in health. The feed backs can then be recorded and analysed qualitatively. Based on these feed backs future plans will be constructed.