Professional Documents
Culture Documents
Leadership QI Project
Crystal Owens
Servant Leadership
I pledge
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Leadership Project
Preventing patient falls in the hospital setting has been a goal for many hospitals across
the nation and the med surge oncology unit I am doing immersion on, also has this goal.
Medicare and Medicaid do not reimburse hospitals for the cost of care related to injuries
sustained in the hospital. The average cost for a fall is over $30,000 according to the CDC
("Costs of Falls Among Older Adults | Home and Recreational Safety | CDC Injury Center,"
2016). After beginning my immersion, a patient managed to flip himself out of his bed during the
night and unfortunately it was a patient walking down the hall that saw him there and alerted me.
It was scary going into a room seeing a person laying facedown in the floor moaning and not
having any information about him. This unit is busy and in the last month already had two
documented falls. Many wonder why this is such a big problem, and one article states “The
challenge of fall prevention is increasing as the inpatient population ages. Both the overall risk of
falling and the likelihood of being injured from a fall increase as people age” (Butcher 2013).
This is a problem that needs more attention but it’s hard when there is not enough staff and the
Heart
A self-serving leader would first be concerned with the costs associated with caring for
those who experienced a fall while staying at the facility. They would also be worried about the
reputation of the hospital as being unsafe because of high fall numbers. A servant leader uses
their heart with pure motives to prevent fall injuries. They are concerned with patient and staff
safety as a priority. They realize the focus should be what’s best for the patient population they
are serving. A servant leader will encourage the hearts of those around them and clear the path
by being a good role model to them. Seeing someone selflessly serve in many cases is the best
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way to motivate others. When educating others on preventing falls by not just focusing on the
financial repercussions of a patient fall and the damage to the reputation you’re making it more
about the patient and what’s best for them. To effectively model the way as a leader you must
have a clear understanding of your own values. No one wants to follow someone who doesn’t
practice what they preach so it’s important that you that are standing up for something you truly
believe in implementing.
Head
The leaders’ beliefs and perspective have a big impact on how they influence those
around them. In the book Lead like Jesus it states: “To engage the hearts and minds of others,
you must be able to communicate these three things: 1. Your purpose, 2, Your vision of the
future, and 3. Your values” (Blanchard & Hodges, 2008, p. 85). Giving a clear definition of your
purpose is important so that everyone you are leading is on the same page. In this case
preventing harm to those you are helping by stopping falls is the goal. Sharing your vision of a
safe and fall free facility can give those around a clear picture of what is expected. Knowing the
values of the company gives employees a blueprint of what is expected so there is no question of
the standard of care they are expected to provide. This is the time you want to inspire others and
enlist others with similar values to get on board with the vision that they have for the long-term
goals of the unit. Therefore, it’s important to work for a company that shares the same values
that you do. You cannot expect to force your views and values on others, but you can try to
inspire them to be more self-motivated. Thinking of ways to increase the budget to hire more
nurses to reduce nurse patient ratios would be a great start to fixing this problem. Many nurses
feel they don’t have enough time to spend with their patients because they have too many to
check on.
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Hands
This is where the action of the servant leader comes into play. Now they must not only
make their goals and values known but they must evaluate the progress and performance of the
people they are leading and serving. In the case of reducing the risk of falls on the unit the
manager would look at the number of falls that occurred to see if the goal was met or at least see
a decline in the number over a period of time. It’s not just a periodic check in but requires “Day
to day coaching and observing their performance, praising progress, and redirecting efforts that
are off base” (Blanchard & Hodges, 2008 p.121). Watching to see what employees on the unit
doing and stepping in to help is part of challenging the process. Watching to see what is working
and what isn’t while looking for opportunities to prevent falls is the only way to figure out what
steps should be implemented. A good manager will talk to their employees to find out what
obstacles they are having in providing safe quality care. In the case of the unit I am doing
immersion on, most nurses are complaining of nurse patient ratios and acuity affecting the
amount of time and attention they can spend with each patient. By hiring more nurses and
reducing the nurse patient ratios nurses will have more time to round more frequently, be able to
respond more quickly to patients’ requests, and respond to bed alarms faster preventing falls
from patients who are attempting to get up and doing things for themselves.
Habits
Today it is very easy to become stressed out and frustrated especially if you are in a
leadership role. Making time in your daily routine to ground yourself and relax is important to
avoid burnout. Habits such as prayer, meditation, and yoga are great practices for reducing stress
and centering the mind. Being centered and calm helps you become a better leader who can
encourage the heart of others. A good servant leader will recognize and show appreciation to
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those around them who do a good job. Public recognition can reinforce good work performance
and encourages others to want to be successful as well. After an inpatient fall there should be a
huddle to discuss the event to try and figure out what went wrong, and how to prevent it from
Nurse patient ratios, staff retention, and recruiting more nurses I feel is key to keeping
patients safe. Having more staff allows nurses to have more time to do their job more effectively.
According to an article published last year; “Authoritative research supports the fact that
strengthening nurse staffing improves quality of care” (Kuwata, K. 2017). If you have too many
patients it makes it harder to implement hourly rounding and provide the good care that is
required to keep our patients safe. By having better ratios nurses will be more likely to stay on
the unit and will have better outcomes and reduce the risk of falls because they will have more
time to devote to the problem at hand. They will have more time to explain to patients the
dangers of getting up by themselves while they are taking certain medications that may cause
drowsiness or dizziness. Nurses do not often have time to discuss all the possible side effects of
Periodic evaluations will help to determine if the goal is being accomplished and to
understand which implanted strategy is working or not working. The outcome results should
speak for themselves by looking at the numbers to see if the fall rate has been reduced but the
numbers alone should not be the only thing considered in an evaluation. During these evaluations
the servant leader should talk to staff members about their perceived success in preventing falls
or problems that they feel are not allowing them to keep their patient safe. By allowing staff to
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express their successes and addressing their concerns they are more likely to feel valued. Happy
staff members that feel valued are more likely to stay on their unit helping with staff retention. I
believe that once staffing levels are improve, nurses will be better equipped to keep closer eyes
on their patients and be able to respond faster to situations where falls could occur.
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References
Blanchard, K. H., & Hodges, P. (2008). Lead like Jesus: Lessons for everyone from the
greatest leadership role model of all time. Nashville, TN: Thomas Nelson.
Butcher, L. (2013). The no-fall zone. Hospitals & Health Networks, 87(6), 26.
Costs of Falls Among Older Adults | Home and Recreational Safety | CDC Injury Center.
https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html