HCM 4040 Module 4 Improvement Team Paper Example

Who Belongs at the Table: Chartering and Running a Falls Team on a Brain Injury Rehabilitation Unit

Student Name

B.S. in Healthcare Management, Thomas Edison State University

HCM-4040: Healthcare Quality and Outcomes: Measurement and Management

Mentor Name

Month Day, Year

Who Belongs at the Table: Chartering and Running a Falls Team on a Brain Injury Rehabilitation Unit

Falls are the most frequent serious safety event on the brain injury unit at Rancocas Valley, the made-up New Jersey rehabilitation hospital whose story runs through these HCM-4040 samples. Last year the unit recorded 6.1 falls per 1,000 patient days, roughly twice the rate on the hospital's orthopedic unit, and two falls caused a fracture. Patients on the unit are often impulsive, have poor awareness of their own limits and are encouraged by therapy to move, so the usual answers of keeping patients in bed or sounding an alarm conflict with the purpose of rehabilitation. The quality council decided that the problem needed a team rather than a new policy. This paper explains why, sets out the team's charter, describes each member's role and the tools the team uses, and explains how the hospital plans to keep the work going after the first results.

Why a Team and Not a Policy

A fall on this unit has many contributors: a patient's cognition, the timing of toileting, medications that cause drowsiness or low blood pressure, the layout of the room, the number of staff on a night shift and how much a therapist encouraged independent transfers that afternoon. No single department sees all of them. Lemieux-Charles and McGuire (2006) reviewed two decades of research on healthcare teams and concluded that gains in patient care came mainly from bringing different kinds of clinical knowledge into the same decisions, while the quality of collaboration and cohesion inside a team mattered most for how satisfied staff felt and how effective they believed the team to be. For Rancocas Valley, the first finding settled the membership question: the team had to include the people who know each piece of the problem. The second finding meant the team's way of working would also need attention.

The Team Charter

The council approved a one-page charter before the first meeting. Its main elements are summarized below.

Roles and Why Each Member Is There

The night nurse and nursing assistant were chosen because two thirds of the unit's falls happen between 9:00 p.m. and 7:00 a.m. and most occur on the way to the bathroom. The physical and occupational therapists bring the knowledge of what each patient can safely do and the tension the team must manage between safety and independence. The neuropsychologist explains how impaired awareness and impulsivity affect a patient's ability to follow a plan, which shapes whether education alone can work. The pharmacist reviews medications that raise fall risk. The family advisor, whose husband fell twice on the unit two years ago, keeps the team focused on how changes look from the bedside and how families can help. The quality analyst prepares the data and keeps the minutes, which frees the leader to run the discussion.

Forrest et al. (2012) found that patients on a rehabilitation unit with lower admission functional scores, and those admitted after stroke, brain injury, amputation or spinal cord injury, were more likely to fall, and that consistent use of nursing protocols cut the share of patients who fell from 14.9% to 7.3%. That study shaped the team's first task: build a short risk review into the admission routine and make sure the agreed steps happen every shift, not only when someone remembers.

Tools the Team Uses

The team uses a small set of tools, each for one purpose. A post-fall huddle, held on the unit within the same shift, asks what happened, why it happened and what will be changed for that patient, and records the answers on a one-page form. Every quarter the analyst groups the forms by time, location and activity so the team can see patterns across falls rather than reacting to each one. A cause-and-effect diagram, built at the second meeting, organized the possible causes of nighttime bathroom falls under patient, staff, environment, medications and routines. Each proposed change gets a trial on a single hallway, run as a Plan, Do, Study, Act cycle, before the whole unit adopts it. The first test was a scheduled toileting round at 11:00 p.m., 2:00 a.m. and 5:00 a.m. for patients flagged at admission.

Making the Team Work Together

Teams fail as often from how they work as from what they try. The team agreed on three ground rules at its first meeting: anyone may question a proposal regardless of position, a fall is discussed as a system problem rather than a staff failure, and decisions and owners are written before the meeting ends. The leader rotates who opens each meeting with a story from the floor so that night staff, who often cannot attend in person, are heard through a colleague. Disagreements are expected. In the third meeting the therapists objected to a proposal to require staff assistance for every transfer, arguing that it would undo weeks of training; the team settled on a color-coded sign at each bedside that states the level of help the patient currently needs, updated by therapy each afternoon.

Sustaining the Work

Improvement teams often see early success fade once attention moves elsewhere. Zalanowski et al. (2024) described a project on the brain injury unit of a larger rehabilitation hospital that used champions, reminders, feedback and local adjustments to raise the collection of standard outcome measures; adoption rose and held for two to four years, but completeness slipped over time. Rancocas Valley's plan responds directly to that risk: the post-fall huddle and bedside sign will be written into unit procedures, the falls measure will stay on the monthly dashboard after the team disbands, and two nurses will serve as standing champions with protected time each month.

Conclusion

Falls on a brain injury unit come from many sources and no single department can fix them. A chartered team that brings each kind of knowledge to the table, works under clear rules, uses a few well-chosen tools and plans for its own ending gives the hospital the best chance of reducing falls without taking away the independence that rehabilitation is meant to build.

References

Forrest, G., Huss, S., Patel, V., Jeffries, J., Myers, D., Barber, C., & Kosier, M. (2012). Falls on an inpatient rehabilitation unit: Risk assessment and prevention. Rehabilitation Nursing, 37(2), 56-61. https://doi.org/10.1002/RNJ.00010

Lemieux-Charles, L., & McGuire, W. L. (2006). What do we know about health care team effectiveness? A review of the literature. Medical Care Research and Review, 63(3), 263-300. https://doi.org/10.1177/1077558706287003

Zalanowski, S., Riley, E., Spaulding, A., Hansen, E., Clooney, D., Modoono, C., & Evans, E. (2024). Connecting practice to data: Implementation strategies to increase collection of core outcome measures in an inpatient rehabilitation facility. Journal of Head Trauma Rehabilitation, 39(6), 425-434. https://doi.org/10.1097/HTR.0000000000000987