NURS FPX 6410 Assessment 2 Executive Summary to Administration

NURS FPX 6410 Assessment 2 Executive Summary to Administration

Executive Summary: Fall Prevention Program for City Hospital, New York, for Patients Over 60

Falls are a leading cause of injury for patients over 60, resulting in decreased quality of life, increased healthcare costs, and higher mortality rates (Ang et al., 2020). The purpose of this executive summary is to provide the City Hospital, New York administration with a plan for implementing a fall prevention program specifically for patients over 60.

NURS FPX 6410 Assessment 2 Executive Summary to Administration

Target Audience

This study’s target audience is patients over 60 (elderly population). This summary is directed toward the administration of City Hospital, New York. The goal is to provide them with accurate and concise data, information, and plans for reducing falls among patients over 60.

Plan-Do-Study-Act (PDSA) Model

The fall prevention program will use the PDSA model, a proven quality improvement framework. This model involves iterative testing of interventions and continuous improvement based on feedback (NHS, 2021). Using the PDSA model, the organization can ensure that the fall prevention program is effective and efficient for patients. To ensure compliance with HIPAA and national standards of practice, the organization can follow these steps:

First, in the Plan phase, the organization will identify the problem, set goals, and develop an implementation plan. Then in the Do step, the organization will implement the plan on a small scale to test its effectiveness. Meanwhile, the organization will evaluate the plan’s effectiveness by collecting and analyzing data. And in the Act step, the organization will modify the plan based on the data and feedback collected in the Study step.

HIPAA Compliant Spreadsheet

The organization will create a HIPAA-compliant spreadsheet to protect patient confidentiality and sensitive information. This spreadsheet will securely store all data collected on patients over 60. Access will be restricted, and the authorized personnel will access only de-identified data. The data includes quantitative information, i.e., DOB, weight, height, BMI, days of stay, and expenses. HIPPA-compliant spreadsheets are important because it ensures that sensitive patient data, such as names, medical conditions, and treatment plans, are kept confidential and not shared with unauthorized personnel. Also, compliance with HIPAA regulations is important for protecting patient privacy and avoiding legal penalties. A hospital that fails to comply with HIPAA regulations may be subject to fines and legal action. In the meantime, it helps to improve efficiency and accuracy in managing patient data. With a well-designed spreadsheet, hospital staff can quickly access and update patient information, reducing the risk of errors and improving overall patient care. Overall this will help improve efficiency and accuracy in managing patient data. With a well-designed spreadsheet, hospital staff can quickly access and update patient information, reducing the risk of errors and improving overall patient care.

Standards of Practice

The fall prevention program will be based on evidence-based guidelines and standards of practice established by national organizations such as the ANA, Joint Commission, and Centers for Disease Control and Prevention (CDC). These standards will be incorporated into the program to ensure that the organization provides the highest quality of care to patients over 60. ANA, CDC, and the Joint Commission provide specific provisions to help reduce the risk of falls in hospitals. One such provision of the CDC is STEADI (Stopping Elderly Accidents, Deaths, and Injuries) Initiative (Kannoth et al., 2021). This initiative provides guidelines and resources for healthcare providers to screen, assess, and intervene to prevent falls among older adults. It includes recommendations for assessing fall risk, modifying environmental hazards, promoting physical activity, and educating patients and caregivers. Also, the Joint Commission’s National Patient Safety Goal on Falls Prevention requires hospitals to assess and periodically reassess patients for the risk of falls, implement strategies to prevent falls, and educate patients and families about fall prevention (Lopez-Jeng & Eberth, 2019). Meantime, ANA guidelines include using bed and chair alarms, ensuring that call lights are within reach, ensuring that patients have appropriate footwear, and using low beds for patients at high risk of falls. These provisions and guidelines can help hospitals to bring about changes that can impact the number of falls in the hospitals in several ways. Also, these guidelines and provisions can increase awareness among healthcare providers, patients, and caregivers about the importance of fall prevention and the specific strategies that can be used to prevent falls. It also makes hospitals compliant with the standards of improved screening and assessment. By requiring hospitals to monitor and evaluate fall prevention programs and outcomes, these provisions can encourage ongoing quality improvement and ensure that hospitals continually strive to reduce the risk of falls among elderly patients.

Data Trending

The organization can monitor and analyze data related to falls among patients over 60 to understand the current healthcare outcome. This will include the frequency of falls, the severity of injuries, and the location and time of falls. The organization will use this data to identify patterns and trends that can inform our fall prevention strategies for this patient population.

NURS FPX 6410 Assessment 2 Executive Summary to Administration

Baseline Data and Data Trending

Information gathered at the outset of a study is called “baseline data,” It measures the degree of change after an intervention has been applied. In this regard, the organization can establish baseline data by thoroughly assessing the fall risk and incidence rates of patients over 60. It will then measure this data regularly to track progress and identify improvement areas. This is important for the organization to understand related to safe practice because it clearly explains our interventions’ impact on this patient population and allows us to make data-driven decisions.

Furthermore, the organization can establish data by defining the population that the organization is interested in. Also, the organization will select other data points that include variables of gender, medical history, and mobility restrictions. The data for the baselining of the studies will be gathered through interviews and EHRs. Then the organization can analyze the data to understand the situation the organization is dealing with. In this case, the organization mostly focuses on an elderly patient who is most likely at risk of falls. Baseline studies and trending data from EHRs help hospitals to conduct fall risk assessments.

On the other hand, they can help health practitioners to introduce preventive measures. For example, suppose a particular time or day of the week is associated with a higher risk of falls. In that case, hospitals can implement measures such as increased staffing, improved lighting, or changes in patient care routines during those times.

Regulatory Information

The organization can use regulatory information supporting informatics as science to produce safe practices. This includes compliance with HIPAA regulations and other regulations and guidelines established by regulatory bodies such as the Joint Commission and CDC. By adhering to these regulations and guidelines, the organization can ensure that our fall prevention program for patients over 60 is based on the best available evidence and provides the highest level of safety for this patient population. HIPAA provides specific guidelines regarding using nursing informatics to protect patient health information (Kiel, 2022). One such rule is the privacy rule. The Privacy Rule establishes national standards to protect individuals’ medical records and other personal health information. It requires healthcare providers to implement reasonable safeguards to protect the confidentiality, integrity, and availability of protected health information (PHI). Nursing informatics professionals must ensure that electronic health records and other health information systems are designed, implemented, and maintained in compliance with the Privacy Rule.


In conclusion, the fall prevention program for City Hospital, New York, for patients over 60 will use the PDSA model, a HIPAA-compliant spreadsheet, evidence-based guidelines and standards of practice, and data trending to reduce falls and improve patient safety for this vulnerable patient population. By establishing baseline data and adhering to regulatory information supporting informatics as science, the organization can ensure that our program is effective and efficient for this patient population. The organization is confident that our fall prevention program will improve patient safety and decrease healthcare costs for City Hospital, New York’s older patient population.

NURS FPX 6410 Assessment 2 Executive Summary to Administration


Ang, G., Low, S., & How, C. (2020). Approach to falls among the elderly in the community. Singapore Medical Journal, 61(3), 116–121. 

Kannoth, S., Mielenz, T. J., Eby, D. W., Molnar, L. J., Jia, H., Li, G., & Strogatz, D. (2021). Adapted Stopping elderly accidents, deaths, and injuries questions for falls risk screening: Predictive ability in older drivers. American Journal of Preventive Medicine, 61(1), 105–114. 

Kiel, J. M. (2022). Data privacy and security in the US: HIPAA, HITECH and Beyond. Health Informatics, 427–435. 

Lopez-Jeng, C., & Eberth, S. D. (2019). Improving hospital safety culture for falls prevention through interdisciplinary health education. Health Promotion Practice, 21(6), 152483991984033. 

NHS England and NHS Improvement. (2021). Plan, Do, Study, Act (PDSA) Cycles and the Model for Improvement Online Library of Quality, Service Improvement and Redesign Tools NHS England and NHS Improvement (pp. 1–8). 

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