Case Study Context



The top administration at the Young at Heart Nursing Homes (YHNH), a large nursing home chain wants to develop report cards for the chain and compare facilities on a standardized basis. You are contracted to help develop standard indices of quality care at the YHNH affiliated nursing homes and validate those indices. Part of the process you use was to use incident reports on falls, medication errors, etc. to compare institutions but one of your concerns is the consistency of data collection across institutions and.

Case facts



At one of YHNH affiliate nursing homes, the facility managers were asked to start developing continuous quality improvement (CQI) projects, focusing on patient falls and related injuries. Using Donabedian’s paradigm of structure, process, and outcome, you use this model starting from the outcome end and work your way backward to identify structural and process factors that affect patient falls. You review the process of patient transfer to identify the parts of this process that are more likely to result in patient injury as your first priority. Related structural factors also need to be examined. The rates need to be adjusted to account for differences in severity, age, etc. across facilities.

As consultants you are expected to help managers identify structural and process factors that might contribute to falls/injuries during transfer. New protocols are designed and structural features redesigned in one facility or unit on an experimental basis. The nursing staff is trained on new process and structural features.

At the end of the study period, you conduct an evaluative study on training effectiveness.

Evaluation study questions




  • Are the nurses following the new process correctly?


  • Are they using the new or revised equipment correctly?


  • If so, is there a significant difference between fall/injury rates in the unit/facility employing the new approach compared with those who are not?



The answer to these questions will determine if all facilities in the system are to be redesigned and staff retrained, with related expenses weighed against improvements in outcome. Other factors, such as cost savings from reduced falls/injuries are incorporated in the decision making. Another issue is whether facilities with low fall/injury rates have a system that is as effective for their staff/facility as the new protocol.

Case study teaching process




  • This case study usually takes two consecutive classes of 3 hours each working in small groups.


  • Students are given the opportunity to identify the different factors that relate to falls in the structure and process of care that could lead to patient falls and use them to reverse the outcome to “prevent falls”.


  • Students are also expected to design incident report sheet to formulate the data collection component for this CQI project.


  • At the end of the this case study, students are given a data set that resulted from a similar project to analyze and are asked to try to answer the evaluation questions.


  • Statistical comparisons use odds ratio, relative risk, and partial attributable risk. Post implementation statistics are compared to the baseline/benchmark figures.