Commander William Danchanko was concerned with his organization’s efforts to prevent injuries from falls. But the Deputy Director of Nursing at the Walter Reed National Military Medical Center in Bethesda, Maryland, had an aha moment while attending IHI’s Patient Safety Executive Development program that made him rethink what it means to have a safety culture. In the following interview, he describes how this revelation led to a simple yet powerful intervention that has nearly eliminated injuries from falls in his facility.
About the Walter Reed National Military Medical Center
Walter Reed is a military treatment facility, so many of our patients are active duty, retirees, and family members. We have a little bit of everything. We have a [neonatal intensive care unit]. We do labor and delivery. We also take some [Veteran’s Administration] patients.
On rethinking how to prevent injuries from falls
Unfortunately, falls tend to be an unavoidable event in hospitals no matter what you do. The problem is falls with injuries.
Our standard response to a problem had been, “Let’s revamp the policy. Let’s do a training stand down. Let’s look at whether the protocols are being followed in chart audits.”
We understood the issue, we understood the policy, we knew what we were doing, and we were risk stratifying our patients the right way. It felt like the same methods for correcting the problem of falls were being replicated with the same results, so I decided we needed to look at this problem a different way.
On using cultural understanding to create a new falls intervention
Going to the Patient Safety [Executive Development] course changed everything for me. We started working our way through the Framework for Safe, Reliable, and Effective Care, and the part about culture got my attention.
You hear a lot of talk about culture and a lot of times it feels like this enigma. But at the Patient Safety [Executive Development] course, we talked about understanding culture not just in terms of staffing, but also in terms of the patients.
Let’s think, for example, about a lot of my older patients. That generation is hitting 65 now. If I have a falls patient who used to run a machine gun out of a helicopter door in Vietnam, and I say, “You can’t get up to go to the bathroom by yourself,” I can tell you that his response is very colorful. “Are you kidding me? I’ve served multiple tours of duty. I’ve been around the world and back again. Now you’re telling me I can’t go pee by myself?”
But there’s something else about the culture that’s really important. One of the things that we always talk about is you fight for the person standing next to you. When you’re in a firefight, you’re not fighting for Washington, DC, or a politician, or the president. You’re fighting for the men and women that you’re with.
There’s this comradery that everybody has. I’ve deployed in Afghanistan and I have this. The guys [who fought] in Vietnam, different era, different war, but we agree on this. I’m [in the] Navy, but the guys in the army refer to each other as “battle buddies.” You have your battle buddy’s back and they have yours.
When I started thinking about this, I realized that a lot of our falls didn’t happen because bed alarms weren’t on or because someone didn’t know the protocol. They happened because the patients didn’t want to have to ask permission to go to the bathroom. But what if I tell my patient, “I’m your battle buddy. You call me and I’m right beside you. I completely appreciate that you want to go take a leak by yourself. But if you fall, you go down, you could get hurt and you’re going to take me down with you. I’m going to be the one in trouble. You have to call me.”
When you say it like that, you’re making a connection. It has made a tremendous difference. Sometimes it can be a little tongue in cheek, a little cheesy almost. Sometimes we cater [to the patient] and say to someone who’s [in the] Navy, “Hey, I’m going to be your shipmate today.” For [patients in the] Air Force, we say, “I’m going to be your wing man.”
Some people wonder how this works for family. They weren’t on active duty, but they understand this concept just as much because quite often that family member has been that battle buddy or that shipmate [at home].
On the results of their falls intervention
Instead of saying, “If falls are happening, it must be the responsibility of the health care provider who’s failing,” we see [falls] as sometimes resulting from patients exercising their autonomy and sometimes resulting in harm. Almost a year ago, we started doing some training using that change in perspective and it was well-received. We still have falls, but we haven’t had any falls-related injuries. The number of assisted falls is increased from the previous year, but that’s because we had staff members right there doing their job.
On how to apply this intervention in other settings
You have to understand where the patient’s coming from. Some of it is about helping patients understand that they also have a responsibility [to keep themselves safe]. I want to keep them safe, but they also have a role to play.
It’s helpful to understand a patient’s motivations. “What are your goals for today?” “I want to get up and walk” or “I want to get discharged in the next two days.” “Okay. You have a little whiteboard in your room. These are your discharge criteria. You need to have X, Y, and Z, and here’s how we’re going to get to that goal.”
On the patient who convinced him of the value of the intervention
One of my Vietnam veterans was on a medical unit and he was a high falls risk patient for multiple reasons. Let’s just say the nursing staff described his reluctance to ask for help when he got up. He was doing his thing and that was it. I went in there and said, “Hey, I’m your battle buddy today and you’re mine. You had somebody’s back at some point, and somebody had yours. And today I'm that guy. I’m sorry, but you’re going to have to call me if you want to get up.”
I could just see it click. “Okay, this is something I can relate to. This is something I value.” It’s as if he was thinking, “I don’t care if I die in battle. I don’t care if I fall, but I’m not going to let anybody go down next to me.” When I shared what happened, the nursing staff were convinced. “Wow. If it worked with him, that could work with a lot of people.”
On the longer-term implications for patient engagement
Involving the patient in their own care and understanding things from their perspective is going to shape the culture of the facility you work in and health care in general. Let patients take the wheel. We can start the bus and we can get things going in the right way. “You know what? I can sit shotgun and give you directions all day long, but you’re ultimately doing the driving.”