title: Virtual Breakthrough Series, Part 2: Improving Fall Prevention Practices in the Veterans Health Administration.
abstract: The Veterans Health Administration (VHA) implemented a Virtual Breakthrough Series (VBTS) collaborative to help prevent falls and fall-related injuries. This project enabled teams to expand program infrastructure, redesign improvement strategies, and enhance program evaluation.
  
  
  
  A VBTS collaborative involves prework, action, and continuous improvement. Actions included educational calls, monthly reports, coaching, and feedback. Evaluation included assessment of interventions, team capacity and infrastructure changes, and rates of falls and fall-related major injuries.
  
  
  
  Fifty-nine teams completed the project. The majority submitted monthly reports. The average number of interventions per team was 6.66 (range, 1-12; mode = 6). The most frequently implemented changes were staff education; post-fall huddles; data tracking; and classifying falls, handoff communication, and intentional rounding. On a program questionnaire aggregated average summary scores improved from 136.54 (baseline) to 58.26 (follow-up; range, 0-189; p < 0.0001). The mean aggregated fall-related major injury rate for participants decreased from 6.8 to 4.8 per 100,000 bed-days of care (p = 0.02), or 5 major injuries avoided per month. No statistically significant changes occurred for nonparticipants. The mean aggregated fall rate did not change significantly from baseline to follow-up for participants (p = 0.42) or nonparticipants (p = 0.21).
  
  
  
  Teams submitted reports and implemented changes resulting in decreased major injuries related to falls for participating units. Teams also made changes in their fall prevention programs such as classifying how they analyze falls and implementing injury reduction strategies. The approaches used show promise for reducing fall-related harm for inpatients, as well as assisting teams in implementing changes.
authors.affiliation: Health Science Specialist, White River Junction Department of Veterans Affairs (VA) Medical Center, White River Junction, Vermont; Assistant Professor of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Electronic address: Lisa.Zubkoff@va.gov.
authors.forename: Lisa
authors.initials: L
authors.lastname: Zubkoff
authors.affiliation: VA National Center for Patient Safety (NCPS), White River Junction.
authors.forename: Julia
authors.initials: J
authors.lastname: Neily
authors.affiliation: Veterans Integrated Service Network (VISN) 8 Patient Safety Center of Inquiry, James A. Haley VA Medical Center, Tampa, Florida.
authors.forename: Pat
authors.initials: P
authors.lastname: Quigley
authors.affiliation: White River Junction VA Medical Center, White River Junction.
authors.forename: Christina
authors.initials: C
authors.lastname: Soncrant
authors.affiliation: White River Junction VA Medical Center, White River Junction.
authors.forename: Yinong
authors.initials: Y
authors.lastname: Young-Xu
authors.affiliation: White River Junction VA Medical Center, White River Junction.
authors.forename: Shoshana
authors.initials: S
authors.lastname: Boar
authors.affiliation: Director, VA NCPS; Adjunct Associate Professor of Psychiatry, Geisel School of Medicine at Dartmouth.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Mills
mesh_terms: D000058:Accidental Falls / Q000517:prevention & control*; D003299:Cooperative Behavior; D003695:Delivery of Health Care / Q000458:organization & administration*; D019468:Disease Management; D006787:Hospitals, Veterans; D006801:Humans; D007318:Inservice Training; D017146:Models, Organizational; D010348:Patient Care Team / Q000458:organization & administration*; D011785:Quality Assurance, Health Care / Q000379:methods*; D058996:Quality Improvement; D014481:United States; D014493:United States Department of Veterans Affairs; D058014:Veterans Health