Quality Scenario: Reducing Patient Falls

An in-depth guide to leading a quality improvement project focused on reducing falls suffered by patients

Other Workflows Within This Scenario

Workflow

5. Communicate and Sustain Progress

Phase 1: Communicate Results

The initial improvement phase automates the entire Plan-Do-Study-Act (PDSA) cycle to guide teams from planning to execution. During the Plan stage, you can use a library of nationally recognized quality measures and a SMART Goal Wizard to formalize the project’s aim. An AI assistant can then suggest evidence-based interventions from a library of vetted change packages. For the Do and Study phases, a PDSA tracker helps define the scope of small-scale tests, while a simple data log feeds directly into a run chart that is automatically updated. The AI assistant provides automated interpretation of this data, highlighting statistically significant shifts. In the final Act phase, the system provides workflow options to either standardize the change or automatically clone the PDSA cycle to adapt the intervention for another test.

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Here is a workflow to help you communicate your team’s success, sustain your hard-won gains, and celebrate the people who made it happen.

1. Communicate Results

Sharing your story is essential for building a culture of quality. It demonstrates that improvement is possible and that the hospital’s investment in QI yields real results for patients.

Action Plan:

  • Generate a QI Storyboard: Your project is not just data; it’s a story of improvement. Use your platform to automatically generate a one-page A3 or Storyboard report.
  • Automated Report Creation: The platform will pull all the key elements from your project workspace into a single, visual summary:
  1. Problem Statement & Goal: From your project charter.
  2. “Before” Picture: The initial run chart showing the negative trend in falls.
  3. The Intervention: A brief description of the successful change (e.g., Post-Fall Huddles).
  4. “After” Picture: The final run chart showing the new, improved performance.
  5. Team Members: A list of the entire team who contributed.
  • One-Click Sharing: Once the storyboard is finalized, the platform provides one-click options to share it across the organization:
  1. Export to PDF for inclusion in board of directors’ packets.
  2. Generate a Slide for your presentation at the next leadership meeting.
  3. Post to Intranet on a digital “QI Wins” bulletin board for all staff to see.

1.Communicate Results Tool

QI Storyboard Example

Phase 2: Monitor Performance

Once a project is successful, the next phase focuses on communication and long-term monitoring. To share results, the platform can automatically generate a one-page A3 or Storyboard report, which pulls the project’s problem statement, goals, “before” and “after” run charts, and team members into a single visual summary. This report can be shared via one-click options to Export to PDF, Generate a Slide, or Post to Intranet. To sustain the gains, the system transitions the project to monitoring by automatically converting the run chart into a Statistical Process Control (SPC) Chart. This chart is moved to a permanent Performance Monitoring Dashboard, and you can set up automated alerts that send an email notification if performance falls outside of the established control limits.

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2. Monitor Performance

Your improvement work is not done once the project is over. You must ensure the gains are sustained. This moves the project from active management to long-term monitoring.

Action Plan:

  • Transition to a Control Chart: Within the platform, you will mark your project’s status as “Standardized and Sustained.”
  • Automated Monitoring: This action triggers several automated processes:
  1. The platform automatically converts your project’s run chart into a Statistical Process Control (SPC) Chart. This chart calculates upper and lower control limits based on your new, improved performance.
  2. This SPC chart is then moved to a permanent “Performance Monitoring Dashboard” for ongoing oversight.
  3. You can set up automated alerts. If the monthly fall rate ever goes above the upper control limit, the system will automatically send an email notification to you and the unit manager. The alert will read: “Alert: The fall rate on 3 East has exceeded the upper control limit for September 2025. This may indicate the process is no longer stable. Please review.”
  • This automated system acts as a “check engine light” for your process, allowing you to intervene quickly if performance starts to slip, rather than waiting for a major negative trend to re-emerge.

2. Monitor Performance Tool

QI A3 Storyboard Report Template

Phase 3: Recognize the Team

The final phase automates team recognition to celebrate success and motivate staff. When a project is closed, a “Project Celebration Wizard” is launched to automate the process. This tool can auto-populate and Generate Certificates of achievement with each team member’s name. It can also Draft a “Leadergram,” which is a pre-written email template sent to a team member’s manager detailing the project’s success and the employee’s contribution. Additionally, the wizard helps format the project storyboard for internal award nominations and can generate a short summary to Submit to Newsletter, ensuring the team’s hard work is celebrated widely.

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3. Recognize the Team

Meaningful recognition is one of the most powerful ways to motivate staff and encourage future engagement in quality improvement. This final step closes the loop on a successful project.

Action Plan:

  • Launch the “Project Celebration Wizard”: When you close out the project, the platform will launch a celebration wizard to automate the recognition process.
  • Automated Recognition Tools: The wizard will walk you through several options:
  1. Generate Certificates: It will auto-populate “Certificates of QI Achievement” with the project goal and each team member’s name, ready for you and the CNO to sign.
  2. Draft a “Leadergram”: It will create a pre-written email template for you to send to each team member’s direct manager. The email will detail the project’s success and praise the employee for their critical contribution. This ensures their good work is seen by their leader.
  3. Nominate for Awards: The platform can format the project storyboard into an application for your hospital’s internal “Patient Safety Star” award, making it easy to nominate the entire team.
  4. Submit to Newsletter: It will generate a short, celebratory summary of the team’s work, perfect for submitting to the hospital’s weekly employee newsletter.By making recognition easy and multi-faceted, you ensure that the team’s hard work is celebrated widely, reinforcing the value of their efforts and building momentum for the next QI challenge. 
  • By making recognition easy and multi-faceted, you ensure that the team’s hard work is celebrated widely, reinforcing the value of their efforts and building momentum for the next QI challenge.

3. Recognize the Team Tool

Project Celebration Wizard Guidance

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