This project aimed to enhance staff engagement in adopting best practices for early and progressive mobilization, reduce falls, and shorten the length of stay on a medical/surgical unit. A key strategy employed was leader rounding to demonstrate commitment to performance improvement and foster a culture of mobility. The leader standard work team comprised key nursing stakeholders and Quality personnel. The PDSA (Plan-Do-Study-Act) methodology was utilized as a framework to evaluate fall prevention practices. Evidence-based evaluations, guided by Falls and Mobility Standards led to the introduction of a weekly leader rounding tool to assess fall prevention interventions. Key components included fall risk signage, gait belts, CMET completion, bed/chair alarms, and EMR documentation. "Real-time" education was provided, and findings were shared through safety huddle boards. Early mobilization was emphasized to prevent functional decline and falls, while standardized workflows and daily dashboard reviews were utilized to promote a culture of mobility.

The implementation of fall risk signage improved from 60% to 100%, with visual cues enhancing safety by ensuring all teammates were aware of at-risk patients. Standardization demonstrated a 33% decrease in falls on weekends and a 30% decrease in overall falls with implementation. Engagement in fall and mobility practices improved, with the average time to first out of bed decreasing from 4.2 hours in 2023 to 3.1 hours. The average length of stay (LOS) improved from 4.33 days in 2023 to 3.9 days. The integration of leader rounding, Falls & Mobility Clinical Practice Standards, and a site-based Falls Committee observed reduced falls, supported nursing practice, and created a culture of mobility. Leader standard work provided visibility, improved communication, and helped eliminate barriers.

The utilization of evidence-based practices, standard work, visual cues, “real-time” feedback, and sharing of data are key to elevating nursing practice and changing the culture.