Reducing Falls Clinical Community

The following example of the Reducing Falls clinical community shows the breadth of achievement. Falls accounted for 324,000 (26%) of all patient safety incidents in 2011. It was the belief of the board that they would be more successful if they worked to tackle this challenge together.


To reduce falls and harm from falls by 50% by June 2016

Primary Drivers

  • Culture and behaviour
  • Reliable falls care processes
  • Environmental factors
  • Leadership

Tests of Change

24 tests of change were carried out by teams participating in the clinical community. These included:

  • ‘SWARM’ post falls analysis
  • MDT management approach
  • Environmental audits
  • Bay-tagging*
  • Colour-coded falls risk wrist bands
  • Patient notes template stickers
  • Perfect night criteria
  • Toilet-tagging*
  • New risk assessment process / forms
  • Bedside falls risks symbols
  • Vision testing
  • Night-time settling
  • Falls awareness & education campaigns
  • Specialling (1-1 observations)
  • Non-slip socks
  • Twilight shifts
  • Supervised assisted mealtimes
  • Use of ‘VisionSIM’ with training
  • e-learning packages
  • “Call, don’t fall” campaign
  • Dementia friendly environments
  • Policy review workshop
  • Safety walk-rounds
  • Ward environment changes


The Falls Clinical Community concluded in a summit in June 2016.


The period Apr 13-Mar 14 is used as a baseline. There was indication of special cause and the limits were rebased using the period Apr 14-Nov-14. This resulted in a 55.6% reduction in the data, which has been sustained.

The period Apr 13-Mar-14 is used as a baseline. There was an indication of special cause and the limits were rebased using Aug-15 to Feb-16 and projected into the future. This resulted in a 39.3 reduction in the data.
At the summit, data show a reduction in the median “proportion of patients with a fall with harm” by 55.6% and a reduction in the median “proportion of patients with any fall” by 39.3%.

Value was also explored through an adaptation of the “five cycles of value creation” framework developed by Wenger, Trayner and de Latt (2011) for the evaluation of communities of practice. The framework looks at value as a cumulative and multi-layered output, and it’s focus on social learning through to improved performance and redefined baselines lends itself well to evaluating collaborative improvement programmes.

Learning from this community is available to all existing and new members.