FallSafe: are culture clashes good for us?
Frances Healey was clinical co-lead of the FallSafe project and is currently Senior Head of Patient Safety Intelligence, Research and Evaluation at NHS England. She tweets at @FrancesHealey
This week the extended evaluation of FallSafe is available online in Ageing and Ageing. FallSafe was generously funded by the Health Foundation as part of its Closing the Gap programme, and at the programme’s closing celebration I was asked to present on what we had learned. The essence of my answer was ‘culture clashes are good for us’ – something that, with further time for reflection, I still believe.
My co-authors and I were mainly from traditional clinical, research and clinical audit backgrounds and though engaged throughout our careers in improving the quality of care for older patients, a Quality Improvement approach with a capital ‘Q’ and a capital ‘I’ was something of a departure – at least in style if not in substance. In our first encounters we confirmed our stereotypical views of each other’s cultures; our sense of what a complex challenge inpatient falls prevention was must have appeared like nihilism to our improvement advisors, whilst their enthusiasm for new ideas felt like heresy to our evidence-based ethos. This culture clash led to some deep discussions and successful compromises. Between us, we could marshal strong evidence that classic QI approach of identifying ‘at risk’ patients and applying a small number of standard nursing interventions would not work, and we found common ground in our shared insight that reliable implementation of an ineffective intervention is no more use to patients than imperfect implementation of an effective intervention.
So taking the best of both cultures and the evidence base, a standardised set of multifactorial assessments followed by tailored interventions was entirely feasible, and repackaging that into care bundles made the complex seem manageable. And inspiration and ambition to improve patient care began with the project’s clinical co-lead laying down the vision that, just as Formula One racing can say today that no driver has died in an accident since 1994, one day we would be able to say no-one has died from a fall in hospital.
And despite FallSafe’s success, we have a desperately long journey to achieve that vision. Nationally reported data on falls in hospital does not often record the ultimate outcome for the patient in the days and weeks after their injury. Any health professional who has stood as a witness at inquest, though, knows how much the odds are stacked against recovery when an older patient experiences the added insult of a fracture, often compounded by failures in essential care, after the fall. And a pilot national audit showed we are far from reliably delivering the core components of multifactorial assessment and intervention recommended by the new NICE clinical guideline. Some of the more worrying headlines include 70% of hospitals unable to supply new walking aids at weekends to all patients who needed one, 11% of older patients not asked if they had a history of falls, and 23% of patients whose ‘culprit’ medication was not reviewed even after they fell.
So if your hospital is grappling with how to reduce falls, gather all the cultures you can in one room. You’ll need patient representatives who can help you hold to the principle that safety should not mean compromising independence or dignity. Like us, you’ll need a core team of nurses, doctors, therapists and managers who have not only expertise but also willingness to abandon unhelpful professional boundaries. You’ll need committed leaders in each ward, both amongst professional staff and the healthcare assistants who can be equally influential and inspirational on the frontline. Like FallSafe, consider partnering acute wards with mental health units; there is much we can learn from each other. And, maybe, just maybe, alongside embracing your hospitals’ research and clinical audit staff, you might consider encouraging an improvement scientist to come into the room.