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Dear Colleagues,

All organizations commit to create and implement valid, reliable and quality clinical care programs that assure safe patient care that protects while improving outcomes: function, health, and well-being.

Among all the clinical programs implemented in your organizations is your patient safety program, which includes fall and fall-injury prevention programs. Organizations predominately measure the success of these programs by measuring fall, repeat fall, and fall injury rates — yes, these are adverse event outcomes. Rarely do organizations measure the effectiveness of their program structures and processes. I assert that you must have confidence in your program — your structures and your process at the organization, unit, and direct-care level, to verify that your program is working. Your organization must know that all important components of your program are fully operational at all levels, and then measure precise outcomes aligned to program components. We are now discussing program evaluation. Ladies and gentlemen, fall and injury prevention programs are very complex — as complex as pressure injury prevention, and reducing hospital acquired infections.

The first step in designing or redesigning programs is to set goals with outcomes that are measurable, and then to conduct a structured baseline assessment of program strengths and opportunities for program improvement. Tools exist for such an assessment. One assessment resource is the Injurious Fall Prevention Organizational Self-Assessment Questionnaire.

This tool was generated during the Department of Veterans Affairs VISN8 Patient Safety Center’s collaboration with IHI’s Transforming Care at the Bedside (TCAB) funded project. Next, this tool was further developed through National Falls Advisory Council and expert review for face validity, to use for program evaluation and research. As you review this tool, you will see that there 63 components validated by fall experts as essential components of a fall and fall injury program. 

The two main sections of this tool are: Organizational Level and Unit Level.

At the organizational level, there are two subsections: Leadership and Data and Injury Program Evaluation. At the Unit Level, there are six subsections: Fall Injury Risk Assessment Methodology, Screening for Likelihood of Falling, Environmental Safety to Reduce Severity of Injury, Additional Fall risk Assessment if Positive Screen: At Risk for Falls, Post-fall injury assessment, and, Discharge Patient / Family Education. Each component is rated using a Likert-type scale from 0 (no activity) to 3 (fully implemented).

You will decide on your survey populations and methods. This included tool-reported survey results at the hospital level. You will next collect data and complete analysis, followed by selection of program components to enhance. Next steps will require strategic planning, and reassessment of progress toward goals.

This tool has been used to examine strengths and opportunities of fall prevention programs within single hospitals, multi-hospital systems, VA specific populations, i.e. medical-surgical and psychiatry units within and across hospitals, and VA national breakthrough change projects in acute and long term care settings. These three references are provided to detail such program evaluation projects and outcomes. 

Quigley, P.A., Barnett, S., Bullet, T., & Friedman, Y. (2014). Reducing Falls and Fall-Related Injuries in Mental Health: A One -Year Multi-hospital Falls Collaborative. Journal of Nursing Care Quality, 29(1): 1-9.

Quigley, P., Barnett, S. Bulat, T., Friedman, Y. (2016). Reducing falls and fall-related injuries in medical surgical units: 1-year multi-hospital falls collaborative. JNCQ, 31(2): 139-145. doi: 10.1097/NCQ.0000000000000151

Zubkoff, L., Neily, J., Quigley, P., Delanko, V., Young-Xu, Y. & Mills, P. (2018). Preventing falls and fall-related injuries in state veterans homes: Virtual breakthrough series collaborative. Journal of Nursing Care and Quality, 33(4), 334-340.

I hope this information and tool, along with references are helpful to you. If you would like more information, or have questions, please let me know. I would be happy to assist you.


You are welcome to contact me directly if you would like more information: pquigley1@tampabay.rr.com


Thank you for reading about this resource.


Pat Quigley


Dr. Patricia Quigley is a Nurse Consultant, Nurse Scientist, Former Associate Director and VISN 8 Patient Safety Center of Inquiry. She is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation, and her contributions to patient safety, nursing and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.