Client
Advent Health
Industry
Healthcare
Role
UI UX Researcher
Tools / Methodologies
Accessibility testing, User Interviews, Observations, Ethnography, Heuristic, Evaluation, Figma.
Year
2024
This case study examines gaps in fall prevention strategies and how to empower patients beyond restrictive hospital protocols. While hospitals assess fall risk and enforce strict measures, they often lack actionable tools to help patients prevent falls proactively. Through interviews, hospital workflow observations, and case study analysis, our research identifies challenges in patient mobility and highlights the need for clearer communication, personalized education, and tailored recovery plans.
My primary contribution focused on UX research, using research methodologies to gather insights into patient experiences, hospital workflows, and gaps in existing strategies. In collaboration with AdventHealth Avista, our team gaol was identify these gaps in fall prevention protocols used at advent health and identify way to incorporate with a patient-centered approach.
Overview
About
AdventHealth is a healthcare system with a vast network of hospitals, outpatient facilities, and clinics across the United States. They focuses on holistic patient care with a commitment to innovation, patient centered care, and advanced medical technology, AdventHealth serves diverse communities by providing high-quality healthcare services, medical research, and education.
Falls are the most frequently reported safety incidents in hospitals. They are not merely accidents or an inevitable part of aging but result from a combination of intrinsic (individual) and extrinsic (environmental) factors, often influenced by a patient’s behavior and risk level.
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Scope
Falls can cause anything from minor injuries to severe harm or even death. Even minor falls are significant, as they can lead to fear of falling, delayed recovery, longer hospital stays, and reduced confidence and independence, impacting both physical and mental health.
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Impact
According to the World Health Organization (WHO), a fall is defined as "an event which results in a person coming to rest inadvertently on the ground, floor, or other lower level." Falls are a major public health concern, especially among older adults, and can lead to serious injuries, disability, and even death.
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Fall
Background
Market analysis
In the US, the CDC estimates that adults aged 65 and older cost the country around $50 billion per year in medical costs related to falls.
The U.S. population is aging rapidly, a trend that significantly impacts the healthcare system, particularly in areas like fall prevention.
Patient Age group
Cost overview
$14,000 - $30,000
Increase hospital costs by per incident
Fall-related injuries in hospitals significantly increase costs, , with severe cases reaching up to $64,526 due to extended stays and additional treatments.
700,000 to 1 million
Each year, hospital falls in the U.S. cause 250,000 injuries and up to 11,000 deaths, affecting 2% of patients, with 1 in 4 falls causing injury and 10% leading to serious harm.
Patient falls occur in U.S. hospitals
Both public and private hospitals across the U.S. are major consumers of fall prevention products.
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Hospitals and Healthcare Facilities
Facilities that care for elderly patients, such as skilled nursing facilities (SNFs), rehabilitation centers, and assisted living centers, are another significant user base.
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Nursing and Rehabilitation Centers
With an increasing number of patients receiving care at home, home healthcare agencies are adopting wearable technologies and fall detection devices for monitoring high-risk patients remotely.
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Home Healthcare Providers
The primary users of fall prevention technologies and strategies
Potential Market
The market is expected to grow at a compound annual growth rate (CAGR) of approximately due to rising healthcare expenditure and advancements in healthcare technology
Annual Market Growth
CMS guidelines and penalties for fall-related injuries are pressuring hospitals to invest in effective fall prevention programs, including biosensors, patient monitoring systems, and evidence-based training programs
Regulatory Impact
The fall prevention market in healthcare is poised for significant growth.
Market Growth
7.5% from 2023 to 2030
Key Competitors
Specializes in fall prevention products such as non-slip footwear, floor mats, and chair alarms designed for healthcare settings.
Medline Industries
Offers a suite of solutions including real-time patient tracking, wearable devices, and fall detection systems, widely used in hospitals and long-term care facilities.
Stanley Healthcare
Provides personal emergency response systems (PERS) and fall detection devices, used both in hospitals and in home healthcare settings.
Philips Healthcare
AHRQ provides evidence-based fall prevention toolkits and training programs for hospitals, focused on implementing fall prevention strategies tailored to different healthcare environments
AHRQ (Agency for Healthcare Research and Quality)
RESEARCH METHODOLOGY
Hospital Staff
Methodology : Ethnography
Location : Advent Health, Louisville,Co
Date : September 30 2024
Participants
Site visit
Research Questions
01
What approach does AdventHealth use to assess fall risk in patients and what specific factors are prioritized?
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What are the primary challenges hospital staff face in implementing fall prevention protocols?
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How are patients and caregivers involved in the fall prevention process, and what materials or instructions are provided to them based on the assessed risk?
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How frequently are fall prevention protocols reviewed, and what feedback or data is collected from fall incidents to improve these protocols?
Client Goal
“Ideal solution would be having zero falls, with assisted falls being the second-best option”
Fall prevention is a collective responsibility of all staff members, with a harm prevention committee and charge nurses overseeing the daily management of high-risk patients.
In 2024, the hospital's fall rate remained low, with only minor injuries reported. However, even minor incidents impact quality metrics and patient safety scores, influencing overall hospital performance.
Fall Reporting at Advent
Solutions at Advent
limitations of these tools highlight the need for any future solutions to be approached from multiple angles. It’s essential to consider both patient comfort and practical intervention capabilities to develop more effective fall prevention measures.
Evaluating solutions
Challenge at large
Challenges in fall prevention include insensitive risk assessment tools, lack of personalized interventions, and the widespread use of generic solutions that lose effectiveness over time. Additionally, there is a need to balance patient independence with safety, particularly for those with normal cognition who may underestimate their fall risk
Key Findings
There is a learning curve for adopting a new fall measurement tool.
Pride plays a role in patient not listening to instructions.
The new measurement tool is very comprehensive (if implemented correctly).
Overarching goal is to limit serious injuries from falls, not eliminate falls.
Fall risk assessments are completed for all patients with risk factors.
All staff members are responsible for fall prevention.
Stakeholders
Patients and Families
Nurses and Caregivers
Primary
Hospital Administrators
Quality Assurance Teams
Secondary
Healthcare Insurers
Hospital Legal Teams
Tertiary
User Story: As a nurse, I want to keep track of many patients at a time and have knowledge of who needs more 1:1 support so that I can be there or assign someone else on staff to monitor them in case they try to get up on their own and risk falling.
Role: Nurse
User Story: As a patient, I want to balance having independence and not burdening anyone with requests for help with staying safe in the hospital so that I can go back home without sustaining additional injuries.
Role: Patient
User Story: As a patient safety program manager, I want to ensure that everyone on the medical team has the tools and training they need so that we can collectively reduce falls in the hospital.
Role: Patient Safety Manager
User Story: As a physical therapist, I want to work with patients on their strength and provide other hospital staff with information on patients physical abilities and limitations so that they can account for it in fall risk mitigation plans.
Role: Physical Therapist
User Stories
Head Nurse
Methodology : Ethnography
Location : Remote meeting
Date : October 16 2024
Participants
User Interview
Research Questions
01
Could high-risk patients with normal cognitive function be an effective focus for fall prevention efforts?
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What communication challenges do hospital staff encounter when discussing fall prevention instructions with high-risk patients?
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How do nursing staff currently assess a patient’s willingness and ability to follow fall prevention instructions, and what role do factors like patient autonomy and dignity play in this process?
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What communication strategies do hospital staff use for fall prevention, and how are these approaches tailored to meet the unique needs of each patient?
Key Findings
Impulsivity is a key risk element with many underlying factors.
Solutions should make patients feel empowered to speak up and feel heard.
Patients have a lot of information thrown at them.
There are a lot of existing tools for nurses and doctors, but not patients.
Most instructions today are communicated verbally.
Patients often feel confident in their stability, overlooking the guidelines.
Patient
Methodology : Ethnography
Location : Remote meeting
Date : October 22 2024
Participants
User Interview
Research Questions
01
How do high-risk patients perceive fall prevention instructions and strategies designed by the hospital?
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what specific aspects contribute to their frustration with Hospital measures?
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What alternative approaches or additional support could have improved high-risk patients' experiences and reduced their frustration with hospital fall prevention measures?
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What factors lead high-risk patients to disregard fall prevention instructions, despite being informed of their potential risks?
Key Findings
Educational materials feel generic and are often standardized across hospitals.
Seeking balance between risk and gaining independence.
Hospital risk aversion negatively impacts readiness to go home.
Desire for more progressive path to become more independent.
Being a “good patient” is important to respect staff.
Desire to be more involved in goal-setting.
RESEARCH
SYNTHESIS
Need Statement
A way to prevent high-risk, normal cognition patients from disregarding hospital staff instructions in order to decrease serious patient injury.
Progressive path for recovery
Lack of individualized guidance and control, Patients are frequently told what to do but not why or how it helps them. This strategy provides a structured, personalized journey that breaks recovery into achievable steps. By pacing recovery and aligning goals to the patient’s ability and emotional readiness, it builds autonomy and confidence, making healing feel possible and within reach.
Empowered Understanding
Poor communication around what it means to be at fall risk & failure of generic instructions, When patients are labeled “fall risk,” they often don’t understand what it truly means for them. This strategy focuses on delivering clear, relatable, and patient-specific education that fosters acceptance and self-awareness. Instead of passive compliance, patients are encouraged to understand their own condition, recognize risks, and actively engage in prevention—laying the foundation for long-term behavior change.
Holistic Healing
Fragmented care that overlooks the mind-body connection, True recovery requires attention to both physical and emotional well-being. This strategy ensures daily physical and mental assessments to adapt care in real time. By modifying mobility plans and exercises based on evolving physical abilities and mental state (such as anxiety, motivation, or fear of falling), patients receive truly personalized care that supports healing as a whole person—not just a diagnosis.
Supported and Continued Care
Post-discharge disconnect and care fragmentation, Patients often feel abandoned or lost once they leave the hospital or transfer to rehab. This strategy ensures continuity of care across settings—hospital, home, or rehab—by creating a clear care pathway and keeping communication and support consistent. It reinforces follow-ups, shared records, and cross-setting collaboration so patients aren’t left navigating recovery alone.
FEATURE
SYNTHESIS
A tool that empowers patients to collaborate with healthcare providers to identify and address fall risk factors, enabling proactive, personalized prevention through a continuous system of care, both in-hospital and beyond.
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Daily Assessment
Emotional Assessment, Understanding a patient’s emotional state helps customize exercises and support resources to meet their specific needs.
Mobility assessment, enables realistic goal-setting and safe activity recommendations tailored to the patient’s abilities.
History of Falls / High-Risk factors, Knowing prior fall incidents or risk factors enables the app to proactively address and mitigate specific risks
Goal Setting
Library of goals for fall prevention and mobility, with options to select or create custom goal
Tracks progress toward goals, helping patients see their improvements over time and stay motivated.
Timely reminders to engage in and complete their exercises. As a source of encouragement.
Reward System
Earn badges for completing planned tasks and maintaining consistent participation, such as Task Achiever or Consistency Champion.
Progress summery are sent to nurses, supporting effective resource management and personalized care.
Tracks progress and achievements to help patients level up, encouraging them to take on new challenges and continue their improvement journey.
Dynamic Dashboard
Self-Guided Learning, Patients can independently explore educational resources like videos and tutorials, promoting better understanding
Accessibility and Preferences, Offers videos, tutorials, and print options, allowing older patients to follow instructions in their preferred format.
Accessibility Considerations
