Imagine you are the assistant director of ABC Surgical Center, a free-standing surgical center that typically sees outpatient surgical patients with same-day discharge, though the facility is staffed and prepared for overnight stays when they are required. Unfortunately, the center has experienced five patient falls within the past 30 days (during which there were only 187 patient days which is a rate of 26.74 falls per 1,000 patient days). You have suggested new quality improvement initiatives based on an analysis of the center’s organizational metrics listed in the chart below. Your manager, the director of ABC, questions the need for the change and the validity of the evidence-based literature you shared with her. The director has asked you to write a memo justifying the need for change. You have decided to also include a discussion on the validity of the research in the memo.

Current-Year Organizational Metrics for ABC Surgical Center
QuarterPatients DaysFallsNumber of Falls per 1,000 Patient Days15760026061((1×1,000)/606) = 1.6536592((2×1,000)/659) = 3.0346542((2×1,000)/654) = 3.06

Prompt
Evidenced-based literature is the foundation of policy and decision making in healthcare. Prepare a report discussing at least two of the following evidence-based literature in your memo.

Clinical and Safety Performance Metrics PDF, by the NIH
Older Adult Falls Data by the CDC
Falls by AHRQ
Preventing Falls in Hospitals by AHRQ
Provide specific evidence from at least two scholarly sources to support your claims.

Specifically, you must address the following criteria:

Elements of evidence-based literature: Identify the critical elements of evidence-based literature in your chosen reports.
Report validity: Defend the validity of the report.
How was the data collected?
How would you assess the credibility of the report’s source?
How would you assess the validity of the report’s conclusions?
Report applicability: Discuss how your chosen report may or may not be applicable to your surgical center.
Metric comparison: Compare your surgical center’s metrics with data from your chosen evidence-based reports.
Recommendations: Recommend changes for your surgical center based on the chosen evidence-based reports.
How rapidly should your recommendations be implemented?
Organizational culture improvements: Discuss potential organizational culture improvements the director would be creating by adopting your recommendations.