Implementation of evidence-based fall prevention strategies: MQI 2021 Incentive Program

September 17, 2021

WSHA remains committed and engaged with our hospitals in implementing evidence-based strategies to reduce patient harm related to falls.

Two key components of a fall prevention program include a root cause to learn why the fall occurred and learning opportunities to reduce and mitigate fall risks in your facility by stratifying fall outcome data. Implementing the post-fall huddle in your facility and leveraging WSHA’s member data repository, the Quality Benchmarking System (QBS), supports best practice and data stratification opportunities.

In collaboration with the Health Care Authority Safety Net Program, the 2021 WA State Medicaid Quality Incentive supports this aim. This year, facilities participating in the incentive program have data elements to submit for this fall measure that are:

  1. All Falls: Total number of all facility falls, with or without injury (whether assisted by a staff member or not) in any facility licensed care area during the calendar month. Anchor
    1. Included populations: Inpatients, short stay patients, observation patients, emergency room, neonates, pediatrics, maternal ward, behavioral health, rehabilitation units.
  2. Post-fall huddle: Submission of an attestation at the end of the MQI period verifying completion of a post-fall huddle with each documented fall within facility during the 6-month performance period.

QBS continues to support the voluntary data submission for falls. All facilities are encouraged to submit data on all falls, repeat falls, types of falls, age-based populations and compliance for the facilitation/conduction of the post-fall huddle.

For members participating in the MQI 2021 Program, WSHA would like to provide additional guidance for entering your data within QBS that supports the data-reporting requirement for the MQI Incentive Program.

Facilities will need to document:

  • All Falls: How to calculate: Numerical value of all total falls that occurred during month (ex. 2 in ED + 1 in MedSurg + 1 in OB + 1 in ICU + + in 1 Behavioral Health = 6 for the month).

For data elements listed as “repeat falls” and those that may not be applicable for the 2021 MQI Incentive, you may enter “-1” in the field. This “-1” is the numerical version of “N/A” in the QBS database.

  • Post Fall Huddle (PFH): Submission of an attestation at end of MQI period verifying completion of a post-fall huddle with each documented fall within facility during the 6-month performance period

Access additional fall prevention resources online or send questions to Amy Anderson at (Amy Anderson)


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