Year of Publication


Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Lynne Jensen

Clinical Mentor

Jessica Sass

Committee Member

Dr. Elizabeth Tovar


BACKGROUND: Unintentional falls commonly arise and can cause significant harm including fractures, head injuries, and death. Assessing each patient for falls and performing a fall risk assessment is recommended by the American Geriatrics Society and the Center for Disease Control and Prevention, and is mandated for institutional reimbursement. Fall risk assessment has been shown to decrease the rate of falls and healthcare costs.

PURPOSE: The purpose of this quality improvement project was to improve compliance for fall risk screening and documentation to meet MACRA requirements in a family medicine clinic.

OBJECTIVES: The objectives for this project were: 1. Conduct PDSA cycles to determine best practice for the assessment and documentation of fall risk within one team. 2. Implement best practices clinic-wide for assessment and documentation of fall risk as identified in PDSA cycles. 3. Compare fall risk documentation reports pre and post-implementation.

METHODS: Conducted and analyzed three PDSA cycles between October 2017-March 2018.

SAMPLE: All patients who were seen from October 01, 2017 to March 01, 2018 were included in this study. This clinic had a total of 16346 patients.

RESULTS: Overall, there was improvement with fall risk screening and documentation. Clinic-wide fall risk documentation compliance improved from 1.2% pre-intervention to 29.2% post-intervention.

DATA ANALYSIS: Monthly data reports were collected and compared to assess compliance to fall risk screening and documentation.

CONCLUSION: Utilizing the Model for Improvement through PDSA cycles is an effective way to generate change. Successful strategies to improve compliance included frequent reminders and administrative support. Identified barriers included time constraints and staff motivation.