Driving Change: Falls, Readmissions and Sepsis Rooted in Strong Foundation

Driving Change

Driving Change is a monthly feature that highlights the work of Michigan hospitals and the Great Lakes Partners for Patients Hospital Improvement Innovation Network (GLPP HIIN) and provides resources to guide improvement.

This month’s focus is on three priority areas — sepsis and septic shock, falls with injury, and readmissions.


An estimated 1.7 million people in the U.S. get sepsis each year. It is currently the leading cause of mortality in U.S. hospitals, with 270,000 reported deaths annually. Protocols for early recognition and treatment are key to effectively managing septic patients.

The MHA Keystone Center, in partnership with Vlasic & Roth, developed sepsis resources to help organizations with metrics and accountability. These resources, in addition to a starter pack, gap analysis, articles, webinar recordings and toolkits, are available on the MHA Community site.

Falls with Injury

Any patient of any age or physical ability can be a falls risk due to physiological changes derived from a medical condition, medications, surgery procedures or diagnostic testing that alters their mental state. According to The Joint Commission, 30% to 50% of patient falls result in injury each year. 

Sparrow Clinton Hospital in St. Johns set out to achieve a record number of days with no injury due to an inpatient fall. Staff members reevaluated processes and procedures, sparking a cultural change within the organization. One change included adhering to the Morse Fall Scale upon admission and on every shift. This scale and other falls prevention resources are available on the MHA Community site.


Readmission following hospitalization is common, expensive and preventable. In 2011, the Agency for Healthcare Research and Quality reported that 30-day, all-cause hospital readmissions were associated with approximately $41.3 billion in hospital costs, making it one of the costliest events to treat.

The GLPP HIIN launched the Bridge Model pilot project in 2017, which included a cohort of 10 hospitals across Michigan and Illinois. Participants received intensive coaching and focused assistance on how to reduce readmissions for their most vulnerable older-adult patients over a 10-month period. The overview of the model, including key strategies and lessons learned, is available on the MHA Community site.

The Illinois Health and Hospital Association created the Readmissions Implementation Playbook, which outlines key concepts, strategies, steps, successes and barriers aimed to address emergency department recidivism and unnecessary hospital admissions and readmissions. Additionally, the GLPP HIIN hosted the Sepsis Readmissions Regional Learning Session, which discussed prevention, discharge planning and post-discharge support.

Foundational Concepts

Reliability culture, health equity, and person and family engagement (PFE) are the foundational concepts that create strong roots for quality improvement. By solidifying a strong foundation, organizations may increase improvement in sepsis, falls with injury, readmissions and other areas of harm.

The Reliability Culture Implementation Guide emphasizes the development of a strong safety culture with the five principles of high reliability organizations — preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resiliency and deference to expertise. The guide provides improvement tools for all facilities, regardless of their progress in the high reliability journey.

Each organization should be actively collecting and analyzing patient demographic data to identify disparities and where to target their efforts. This includes race, ethnicity, language, sexual orientation, gender identity and other social determinants of health factors. Additionally, hospitals should ensure access to quality, culturally competent care for vulnerable populations.

PFE is an integral part of the hospital culture. The MHA Keystone Center encourages all facilities to form a Patient and Family Advisory Council to engage patients and families in reducing inpatient harm.

For guidance on effective implementation of evidence-based practices, contact the MHA Keystone Center to request no-cost implementation support consultations with performance improvement experts. 

Members with questions may contact the MHA Keystone Center.