1. Department of Mechanical and Industrial Engineering
Faculty of Applied Science & Engineering
University of Toronto – St. George
MIE561H1 Healthcare Systems
Case Report 4:
Falls Reduction at KPMG’s Client Hospital
Submission Date: April 5, 2016
Group 11
Group Member Name Student Number Email address
Zacks Pan 999431271 zacks.pan@mail.utoronto.ca
Farabi Shireen 998986414 fshireen@gmail.com
Ronald Hoffer 995386620 ronald.l.hoffer@gmail.com
2. 1
EXECUTIVE SUMMARY
KPMG Consulting is currently working to reduce the number of preventable patient falls in a
hospital in Southwestern Ontario. The hospital, which sees mainly elderly patients, currently
incurs approximately 300 preventable falls per year. The majority of the falls occur between
midnight and 5:00 am by elderly patients attempting to ambulate to and from the restroom. The
hospital wants to reduce the number of preventable falls by 25% over the next year, while
working towards the longer term goal of making itself into the safest hospital in Canada.
Previous efforts by the Seniors Friendly Committee (SFC) to reduce the number of falls have not
made a considerable impact, and the annual rate of falls within the hospital has remained
consistent for the past five years.
Investigation of the problem has revealed a lack of physical patient restraints, inadequate night
time lighting, long nurse response times to patient call bells, and a lack of stakeholder
involvement as the four root causes of the problem.
The authors have considered three main solutions. The first is to increase stakeholder
involvement by allowing overnight visitors in patient rooms and recruiting willing patients and
their family members to the SFC. The second is to install a smart lighting system in patient
room. The system detects when a patient is waking up to use the restroom and automatically
illuminates a path to the restroom, with the lighting level being neither too dim to be useful nor
too bright to be comfortable to a freshly awakened patient. The third solution is a second
generation bed alarm that uses reduces the nurses’ workload. By reducing the attention a nurse
must give to patients that have a low risk of falling, it enables nurses respond more quickly to
patient call bells. The consequent reduction in nurse response time to call bells means that
patients are more likely to use the call bells and wait for the nurses.
The solutions were compared to each other on several criteria, including implementation
difficulty, implementation time, cost, reliability, patient satisfaction, nurse satisfaction and
impact on reducing risk of falling. The comparative evaluation revealed the second generation
bed alarm as the preferred solution.
In the long-term, we recommend that the hospital increase its data collection from falls to better
understand where, when, and why falls are happening.
3. 2
1.0 INTRODUCTION
KPMG Consulting is currently working to reduce the number of preventable patient falls in a
hospital in Southwestern Ontario. The hospital, which sees mainly elderly patients, currently
incurs approximately 300 preventable falls per year. The majority of the falls occur between
midnight and 5:00 am by elderly patients attempting to ambulate to and from the restroom. 75%
of these falls occur within the cardiac surgery ward, the elderly care unit, the inpatient cardiology
ward, the inpatient chest ward, and the inpatient medicine ward.
The hospital wants to reduce the number of preventable falls by 25% over the next year, while
working towards the longer term goal of making itself into the safest hospital in Canada.
Previous efforts by the Seniors Friendly Committee (SFC) to reduce the number of falls have not
made a considerable impact, and the annual rate of falls within the hospital has remained
consistent for the past five years. These efforts have included the installation of bed alarms,
mobility checks for equipment, non-skid socks, the distribution of pamphlets to educate patients
and family members about preventable falls, falls risk assessments for all patients, and visual
display board management of patients at risk of falling.
Govind from KPMG has asked the student teams of the MIE561 Healthcare Systems class to
suggest process-related and cost-neutral solutions to reduce the number preventable patient falls
while maintaining a high quality of care and increasing patient and staff satisfaction.
2.0 PROBLEM DEFINITION
Govind provided several details about the problem. As mentioned in the introduction, the
greatest number of preventable falls occurs to elderly patients ambulating to and from the
restroom between the hours of midnight and 5:00 am. Falls also occur when patients get out of
bed in general, when patients stand up from a seated position, and when patients being
transported through the hospital. Falls can be categorized according to the rating system in Table
1. Approximately 60% of the falls are of level-1 severity. All patients undergo a falls risk
assessment upon being admitted.
Table 1: Level of Severity of Falls
Level-0 Near miss/potential harm/damage
Level-1 No harm
Level-2 Temporary minor harm/damage
Level-3 Permanent harm/damage
Level-4 Death
Every time a fall is known to occur, it is reported and given a rating based on the fall’s severity.
An investigation is then carried out by the patient safety committee. This entails holding a
meeting with the managers to look at safety practices and suggest and implement improvements.
This task is carried out exclusively by two people from the 20-person committee. The committee
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officially meets monthly to discuss the welfare of the hospital’s senior patients, though due to
logistical challenges, meeting typically only take place quarterly.
Nurses at the hospital work twelve-hour shifts. The nurse-to-patient ratio is 1:5 during the
daytime and 1:6 at night. Every 2 hours, the nurses conduct “purposeful rounding.” This entails
checking that each bed alarm is working properly, ensuring that each patient’s call bell is within
the patient’s reach, and checking to see if the patient needs anything.
A significant percentage of the patients take sedation medications. These medications can cause
disorientation and make the patients more prone to falling within eight hours of receiving them.
For the large number of falls that occur as patients ambulate to the restroom at night,
disorientation and low levels of alertness caused by sleepiness and lack of lighting may be
contributing factors.
All rooms are equipped with call bells which the patients are encouraged to use. Once pressed,
the corresponding nurse on duty is alerted that the patient needs assistance, and the nurse
responds as soon as possible. However, nurse response times are often as great as 25 minutes
due to each nurse’s heavy workload. Consequently, patients are sometimes unwilling to use the
call bells, especially when they urgently need to use the restroom.
Although friends and family members of the patients are unable to stay overnight at the hospital,
they are able to visit throughout the day. As a result of this, extra furniture may be brought into
patient rooms during the day. When the visitors leave, they often leave the extra furniture in the
rooms, where they cause clutter. This poses a hazard to ambulating patients, particularly in the
darkness and disorientation of the night.
3.0 ROOT CAUSE ANALYSIS
Potential factors contributing to preventable patient falls are a lack of physical restraint of the
patients, dim lighting in patient rooms at night, long nurse response time to call bells, and the
lack of accountability to the management of implementations by the SFC (see Figure 1). These
issues are described in detail below.
Figure 1: Root cause flow chart for KPMG’s hospital patient falls
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3.1 Lack of physical restraint of patients
Hospital beds are height adjustable, and prior research has suggested that high hospital bed
heights are a contributing factor to falls for patients getting out of bed [1]. As the client is not
aware of any policy of lowering the beds at night, it can be assumed that high bed height is a
contributing factor to some of the preventable falls. Patient beds are also equipped with bed
rails. However, all four rails are often not left up at night. This poses a risk to patients who have
been deemed as “at risk” by the falls assessment. According to the client data, more than three
times as many patients fall from beds with two rails up as opposed to those with three rails up,
and ten times as many from beds with two rails up than that with four rails up (Appendix A). It
can therefore be inferred that lack of deployment of bed rails is a contributing factor to falls.
3.2 Dim Lighting in Patient Rooms
According to the data provided by the client (shown in Appendix B), “confusion/disorientation”
is currently the largest contributing factor and “slipped/tripped” is the third largest contributing
factor to patient falls. It should is known that the most falls occur at night, and it is assumed that
inadequate lighting can contribute to both confusion/disorientation and tripping/slipping, and
assuming that patient room lights are turned off at night, especially in a cluttered room with lots
of tripping hazards. Therefore, it can be inferred that inadequate room lighting at night is a root
cause of the falls.
3.3 Nurse Response Time to Call Bells
Data from the client (Appendix B) lists “needed help, did not use call bell” as the second largest
contributing factor and “toileting required” is the fourth largest contributing factor to patient
falls. As mentioned in the problem definition section, patients often must wait up to 25 minutes
for nurses to respond to their call bells. A patient may wait for the nurse the first few times, but
will soon tire of waiting each time he/she needs to use the washroom. It is likely that the patient
will eventually just skip the call bell and go to the bathroom himself.
3.4 Minimal Role of Patient Safety Committee
The client indicated that there is a lack of feedback to the hospital staff from the SFC following
each fall investigation. Although the number of falls and the reason for each fall are tracked,
there are no consequences for any party. As indicated in the problem definition section, the SFC
typically meets quarterly instead of monthly as it is supposed to. As a result, there has been a
lack of follow up to measure the success of previous changes made to increase patient safety. A
lack of prioritization of falls prevention by the SFC and hospital staff may be preventing the
reduction of the preventable fall rate.
4.0 SCOPE OF SOLUTIONS
The hospital has already implemented solutions such as anti-slip socks and bed. This report will
provide suggestions on improving the effect of existing measures, as well as suggestions of
solutions net yet implemented. The scope of suggested solutions will be limited to those that
reduce the risk of falling and lower the fatality rate of falls that do occur. Suggested solutions
will be limited to those that reduce the falls rate of the largest fall group, which is patients
ambulating the restroom at night. Since the hospital possesses limited resources as well as the
need to maintain a functioning environment, major alterations of the ward’s floor plan are
excluded from the scope. Changes to nurse staffing levels are also excluded from the scope.
6. 5
5.0 RECOMMENDATION SOLUTIONS
5.1 Increased stakeholder involvement
This solution seeks to reduce falls by engaging stakeholders in their prevention.
5.1.1 Patients and family members joining the SFC
Currently, the SFC, which is in charge of designing and implementing measures to reduce falls,
does not view the falls issue as high-priority. This is indicated by the fact that there is a lack of
interest and involvement from the committee to develop a long-term solution. We suggest that
patients and their families be included in the committee from now on. They will not only be able
to offer a new and relevant perspective on the issue, but, as the victims of the falls, they will have
an inherent interest at decreasing the rate of falls.
5.1.2 Allowing overnight visitors
Another method of increasing stakeholder involvement is to allow family members and friends
of the patients to stay overnight. Visiting policies are becoming less restrictive across Canada
[2], meaning family members can now stay overnight in some hospitals. These family members
can be enrolled to accompany the patients on their night time restroom trips. Patients with
family members staying overnight would not have to wait for a nurse to respond to their call bell.
Simultaneously and consequently, patients without overnight visitors will have easier access to
the nurses, meaning that they too will not have to wait as long for assistance to travel to the
restroom.
5.2 Automatic night time lighting system
This solution is based on several assumptions. The maximum number of falls occurs by patients
ambulating from their hospital beds to the bathroom between midnight and 5:00 am. It can be
assumed that the high rate of falls during this time can be largely attributed to the lower level of
alertness that patients have at this time of day. What is therefore needed is a solution that
maximizes the alertness of patients using the restroom at night. It will be taken for granted that
people at night will typically be more alert in a lighted environment than a dark one. It will also
be taken for granted that many people do not like to turn on lights in the middle of the night
because, for eyes that have just been sleeping, regular room lighting levels are far too bright to
be comfortable. It will also be taken for granted that in the hospital setting, which does not have
the same familiar light switch positions as one’s home, night time restroom users will be even
less likely to use the lights, and all the more so in multi-person rooms in which the ambulating
patient does not wish to wake up the other patients in the room.
Therefore, we propose a sophisticated lighting system that will help raise only the awake
patient’s alertness so that he/she can travel safely to and from the bathroom safely. A system of
overhead track lights such as those shown in Appendix C will illuminate only the patient’s bed,
the interior of the bathroom, and the route between the bed and the bathroom. The lighting will
be controlled automatically by a non-contact ResMed S+ sleep monitoring and analysis device
shown in Appendix D [3]. The ResMed S+ uses patented non-contact respiratory and bio motion
sensors to monitor the respiration and movement of a sleeping person. It is programmed with the
intelligence to recognize the patterns of respiration and movement that correspond to various
levels of sleep. It has an alarm clock feature that deliberately and slowly wakes up the patient
when the patient when is in a light phase of sleep. This capability will be used to slowly
7. 6
illuminate the appropriate lights when a patient becomes fully awake in the middle of the night.
The lights will gradually come up to a comfortable dim level that clearly illuminates that
patient’s path to the washroom but does not blind the patient. A source could not be found
indicating the appropriate duration of transitioning from darkness to light, but it will be assumed
to be 15 seconds from the moment of sitting up. When the ResMed S+ recognizes that the
patient has returned to the bed to go back to sleep, it will gradually dim the lights back to
darkness.
The costs associated with the system are the purchase of the $150 USD ResMed S+ device for
each patient [3], the installation of about 10 focussed light fixtures per room at a cost of
approximately $20 CDN each [4], installation labour estimated be about $500 CDN per hospital
room, and computer programmer costs estimated to be $10,000 CDN for the entire project.
Assuming a hospital with 400 beds and 200 rooms and the current exchange rate of $0.76 USD
per $1.00 CDN, the capital cost will be about $193,000 CDN.
5.3 Second generation bed alarm and notification bell
The bed alarm can be improved to track patient activity and predict the patient's likelihood of
getting out of bed. This will reduce the rate of false alarms, thereby reducing nurses’ alarm
fatigue. The bed alarm system will be integrated with a web application to monitor the patient’s
movement and send potential falls message to nurses. The application will provide a time-color
labeling of each patient’s profile. If the patient’s state has any changes, the application will mark
the patient it with a color alert. Green will mean the patient is in the bed and yellow will denote
that the patient has left the bed. When the patient’s state changes from in-bed to out-of-bed, the
system will start a timer and send a “yellow alert” to the nurse on duty. If the patient is gone for
an extended period of time, the nurse will receive a “red alert” that requires the nurse to check up
on the patient. Time analysis will be performed based on washroom time data. Whereas the
current bed alarm sounds whenever the patient leaves the bed, this design calls the nurse only if
the patient stays out of bed. This reduces the number of alarms, thereby enabling nurses to
become more responsive to patient call bells and serious bed alarms.
The second aspect of this design is the notification bell. Unlike the call bell, the notification bell
does not require a nurse’s response. It merely lets the nurse know that a patient has gotten out of
bed to use the restroom. Notification bell buttons will only be given to patients who are deemed
to be at low risk of falling. The result is that patient who can reliably travel to and from the
restroom will not be required to call a nurse to do so. This will further reduce the nurse’s
workload and allow the nurse to focus on the remaining call bells and bed alarm red alerts.
6.0 EVALUATION OF SOLUTIONS
The advantage of the increased stakeholder involvement solutions is that they carry no cost.
However, they rely on factors beyond the hospital’s control. There may not be a large number of
patients with overnight visitors some of the time. There may not be patients or family members
volunteering to join the SFC. The overnight visitor solution also increases clutter in the rooms,
which could actually increase the fall rate.
8. 7
The advantages of the automatic night time lighting system are its predicted effectiveness, its
fully automatic nature, and the relative lack of required training. The disadvantage is its high
capital cost.
This second generation bed alarm carries a moderate capital cost for the software development
and software and hardware installation. However, it carries a low operating cost. It has the
advantage of using the existing bed alarm equipment and patient call bell, though not all beds are
equipped with the call bell. Deploying the system on all beds would increase the capital cost.
The system is expected to be effective at diverting nurse attention to patients who are more likely
to fall without their help.
The solutions are evaluated against each other in As shown in the table, the second generation
bed alarm is the preferred solution. It targets the second- and fourth-largest contributing factors
to falls, costs less than the lighting solution, and is expected to improve both the staff and patient
experiences.
Table 2. As shown in the table, the second generation bed alarm is the preferred solution. It
targets the second- and fourth-largest contributing factors to falls, costs less than the lighting
solution, and is expected to improve both the staff and patient experiences.
Table 2: Evaluation comparison matrix of proposed solutions ranks solutions on a scale of 0 (poor) to 5 (excellent) in
several criteria.
Increased
stakeholder
involvement
Automatic
night time
lighting
system
Second
generation bed
alarm and
notification bell
Implementation difficulty 3 3 3
Implementation time 5 0 1
Cost 5 0 2
Reliability (double weighted) 1 (2) 5 (10) 4 (8)
Patient satisfaction 3 4 4
Nurse satisfaction 3 4 5
Impact on reducing risk of
falling (quadruple weighted)
2 (8) 4 (16) 4 (16)
Total 29 37 39
7.0 CONCLUSION
Reducing the client’s hospital’s rate of preventable falls is a necessary step on the road to it
becoming Canada’s safest hospital. The falls are caused by equipment deficiencies, inadequate
lighting, long nurse response times, and a lack of stakeholder involvement in reducing falls. A
9. 8
comparison of several solutions has revealed a second generation bed alarm as the preferable
solution for reducing the rate of preventable falls.
8.0 FUTURE WORK
While there is some data available that reveals the patterns and causes of the patient falls in the
hospitals, it is incomplete. Indeed, the solutions generated in this report were conceived of based
on some assumptions. Better data tracking is needed to help the nurse staff better understand
where, when, and why patients are falling. This will allow further appropriate anti-fall measures
to be implemented in the future.
10. 9
REFERENCES
[1] A. Huey-Ming Tzeng, "Nursing staff’s awareness of keeping beds in the lowest position to
prevent falls and fall injuries in an adult acute surgical inpatient care setting", Medsurg
nursing : official journal of the Academy of Medical-Surgical Nurses, vol. 21, no. 5, p. 271,
2012.
[2] R. O’Reilly, D. Bournes, M. Stasiuk, and J. Petch, “Canadian hospitals being to open up
visiting hours”, Healthy Debate, 2015. [Online]. Available:
http://healthydebate.ca/2015/03/topic/visiting-hours. [Accessed: 05- Apr- 2016].
[3] "S+ sleep monitoring device | ResMed.com", Resmed.com, 2016. [Online]. Available:
http://www.resmed.com/us/en/consumer/s-plus.html. [Accessed: 05- Apr- 2016].
[4] "Search Results for recessed lighting at The Home Depot", Homedepot.com, 2016. [Online].
Available: http://www.homedepot.com/s/recessed+lighting?NCNI-5. [Accessed: 05- Apr-
2016].
[5] Tectonica-online.com, 2016. [Online]. Available: http://www.tectonica-
online.com/art/images/8bt24.jpg. [Accessed: 05- Apr- 2016].
13. 12
Appendix C: Photograph of focused overhead lights
Overhead lights with narrowly focused beams illuminate predominantly what is directly underneath them. Image from
[5].
14. 13
Appendix D: The ResMed S+ non-contact sleep monitoring device
Photograph of the ResMed S+ Sleep monitoring device. Image from [3].
15. 14
Work Attribution Table
Farabi Ronald Zacks
Report Formatting/Editing MR
Executive Summary FD, ed
Introduction FD MR
Problem Definition FD ed
Root Cause Analysis FD ed
Scope ed FD
Solution 1 FD ed
Solution 2 FD, ed
Solution 3 ED FD
Evaluation of Solutions FD, ed FD
Conclusion FD, ed
Future Work ed FD
FD = First Draft and associated research
MR = Major Revisions
ed = Minor Editing
