As the assistant manager of the facility, you note a fall rate of 5% for the past 3 months. Five percent does not sound like much, but consider the facility sees 3,000 patients a month which means 15 of those patients fell getting into the facility. One of those numbers is Mrs. Jones, an 82-year-old grandmother of nine who makes the best donuts in town and remains active in the community. When entering the facility, she trips on the raised entry-way door sill and sustains a broken hip. At an age where an accident such as this can cause debilitating injury, Mrs. Jones is hospitalized with a fractured hip and after 10 days of confinement dies due to complications of surgery. You are tasked with choosing a quality improvement tool to evaluate the reasons (note there could be many) causing the high number of falls in your facility.

From these qualitative tools:

1. five whys*
2. cause and effect diagram* 
3. decision matrix (FMEA)*
4. flowchart *

Choose the best tool that will help you determine what factors contribute to falls.  Use your best creative thinking. You might consider the structure of the building, how the flow of patients throughout the facility puts patient into jeopardy, obstacles in place, missing assistive devices or personnel that play a part in the outcome of patients seen in your clinic.

*Go to IHI.org, put the tool name in the search box and you will be able to access a resource that has everything you need. There are video instructions and a link that will provide a template for the tool you wish to use.