How and why is change likely to come about?

1 Aug 2014 | Reducing Harm from Falls

Being clear about how and why change will come about is a critical success factor in quality improvement. It means developing a logic or theory about the programme components (the falls prevention measures you decide to implement), their mechanism (how they work and what effect they will have) and the expected outcome. Logic models and driver diagrams can be used to set out these relationships as a ‘theory’ for your programme.

Theory clarification would help to address the problem that improvement interventions are often designed without the benefit of previous learning or explanation of the assumptions about how and why change is likely to occur[1].

Hospital and residential care settings

In hospital and residential care settings, effective programmes will need a mix of components to assess and address person-specific risk factors and a safe care environment, since falls are often an interaction between these two things[2,3].

Reviews have established that multi-component programmes reduce fall rates by about 20 to 30 percent[4, 5, 6]. But since there are a number of components, it’s difficult to tell which ones are working best, and it’s not clear what the ‘ideal’ mix of components is[4].

The challenge for falls champions and leaders in planning a falls programme is to put together a set of components that make sense for your particular situation. Choi and colleagues proposed a model based on their systematic review[3], which could be a starting place for your own work (see page 2520).

We have developed a similar model showing the mechanisms for programme components discussed in the 10 Topics. The model includes links to the resources provided by Reducing Harm from Falls.

Community settings

Single component programmes are more commonly used in community falls prevention[7] – components such as home assessment and modification for higher risk older people or exercise programmes to enhance balance and strength – making the development of a theory as to why change will occur far less complex.

A generic programme logic model written for the Ministry of Health as a guide to developing public health programmes in New Zealand is available here via webpage or PDF. Here is an example of a similar logic model for use in a community-based fall prevention programme: National Council on Aging Falls Free logic model. An evaluation of a statewide programme in Kentucky (population 4.3m) using this model is available here.


  1. Marshall M, Pronovost P, Dixon-Woods M. 2013. Promotion of improvement as a science. The Lancet 381(9864): 419-21.
  2. Miake-Lye IM, Hempel S, Ganz DA et al. 2013. Preventing in-facility falls. In Shekelle PG, Wachter RM, Pronovost PJ, et al. 2013. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality.
  3. Choi YS, Lawler E, Boenecke CA et al. 2014. Developing a multi-systemic fall prevention model incorporating the physical environment, the care process and technology: a systematic review. Journal of Advanced Nursing 67(12): 2510-24.
  4. Miake-Lye IM, Hempel S, Ganz DA et al. 2013. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine 158(5 Pt 2): 390–6.
  5. Cameron ID, Gillespie LD, Robertson MC et al. 2012. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews (12): CD005465.
  6. Oliver D, Healey F, Haines TP. 2010. Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine 26(4): 645–92.
  7. Gillespie LD, Robertson MC, Gillespie WJ et al. 2012. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews (9): CD007146.

Last updated 07/05/2021