Injurious Fall Prevention Organizational Self-Assessment This self-assessment is voluntary; please complete one per facility. Please do not identify any individual by name; this is confidential as to individuals. Hospital Name and station number: _______________________ Unit Type (s) : Circle One or more (for units that you have a team for in the breakthrough series) Med Surg ICU/CCU/SICU LTC Rehab Outpatient / Community Care Directions: Score the level of implementation for each component of your fall-injury prevention program, completing Section 1: Organizational-Level Assessment and Section 2: Unit-Level Assessment. Select a unit and score each item. Consider level of implementation of each component from no activity (0), discussed not implemented (1), partially implemented (2), to fully implemented (3). Circle a numeric score for each item. Fall Injury Prevention Program Attributes Partially Fully No not Activity SECTION 1. Organizational Level A. Leadership Executive with targeted question about fall 0 1 2 3 “walk-arounds” injury prevention Senior management and clinical representatives facilitate 0 1 2 3 periodic, announced, groups (unit briefings) of front line practitioners to learn about perceived problems with fall-related injuries. Employees are provided with timely and routine feedback 0 1 2 3 on fall injury data, improvement results, significant events and near misses* Fall-Injury Prevention strategies target the organizational 0 1 2 3 and unit system, patient populations.* Fall-related injuries are discussed openly without fear of 0 1 2 3 reprisal or embarrassment.* All fall-related injuries are discussed with patients and 0 1 2 3 families regardless of injury severity.* One or more specifically trained practitioners are 0 1 2 3 identified to oversee the analysis of fall-related injuries, their causes and coordinate fall injury prevention activities.* Employees voluntarily report fall injury hazards* 0 1 2 3
Injurious Fall Prevention Organizational Self-Assessment This self-assessment is voluntary; please complete one per facility. Please do not identify any individual by name; this is confidential as to individuals. Hospital Name and station number: _______________________ Unit Type (s) : Circle One or more (for units that you have a team for in the breakthrough series) Med Surg ICU/CCU/SICU LTC Rehab Outpatient / Community Care Directions: Score the level of implementation for each component of your fall-injury prevention program, completing Section 1: Organizational-Level Assessment and Section 2: Unit-Level Assessment. Select a unit and score each item. Consider level of implementation of each component from no activity (0), discussed not implemented (1), partially implemented (2), to fully implemented (3). Circle a numeric score for each item. Fall Injury Prevention Program Attributes No Activity not Partially Fully SECTION 1. Organizational Level A. Leadership Executive “walk-arounds” with targeted question about fall injury prevention 0 1 2 3 Senior management and clinical representatives facilitate periodic, announced, groups (unit briefings) of front line practitioners to learn about perceived problems with fall-related injuries. 0 1 2 3 Employees are provided with timely and routine feedback on fall injury data, improvement results, significant events and near misses* 0 1 2 3 Fall-Injury Prevention strategies target the organizational and unit system, patient populations.* 0 1 2 3 Fall-related injuries are discussed openly without fear of reprisal or embarrassment.* 0 1 2 3 All fall-related injuries are discussed with patients and families regardless of injury severity.* 0 1 2 3 One or more specifically trained practitioners are identified to oversee the analysis of fall-related injuries, their causes and coordinate fall injury prevention activities.* 0 1 2 3 Employees voluntarily report fall injury hazards* 0 1 2 3