Seeing the Whole System: Why Fall Reporting in Nursing Homes Requires a Systems Thinking Approach
The Systemic Nature of the Problem
A federal report reveals that nursing homes failed to report 43% of falls with major injury that resulted in hospitalization, indicating that publicly reported fall rates on Care Compare are likely inaccurate.
This finding, from the U.S. Department of Health and Human Services Office of Inspector General (OIG), exposes not just a data gap—but also a systemic breakdown in how long-term care organizations collect, interpret, and act on safety information.
When nearly half of serious falls are invisible in official data, the problem extends far beyond compliance. It reflects how parts of the system—people, processes, technology, incentives, and culture—interact in ways that obscure risk rather than reveal it.
A systems thinking lens helps explain this dynamic. Every organization is an interconnected whole, and what happens in one part affects all others. When reporting systems, financial incentives, and frontline culture are misaligned, even well-intentioned staff can make decisions that unintentionally undermine safety.
The Core Problem: Skewed Data, Skewed Priorities
The Minimum Data Set (MDS) assessments that capture fall information don’t stand alone. They feed into Care Compare and the Five-Star Quality Rating System—tools meant to guide families and influence reimbursement.
When fall data is incomplete, the entire feedback loop becomes distorted. Leadership receives inaccurate information, quality improvement efforts target the wrong issues, and the public is misled.
The OIG report found that “nursing homes with the lowest fall rates on Care Compare were the least likely to report the falls we examined.” In other words, data designed to support improvement is instead reinforcing a false narrative.
From a systems perspective, this illustrates how feedback loops can drive either improvement or dysfunction. If the feedback (fall data) is inaccurate, the system cannot be analyzed and improved.
Understanding the Incentives and Interconnections
Underreporting doesn’t happen in isolation. It is a symptom of systemic pressures that interact across multiple layers:
- Regulatory and financial systems create incentives to maintain low fall rates.
- Organizational culture reinforces fear of blame.
- Reporting processes may be complex or poorly designed.
- Frontline staff behavior is shaped by leadership response and workload.
When these elements are not aligned, the system produces predictable outcomes—underreporting, missed learning, and continued harm.
Systems thinking invites leaders to step back and look at how these parts work together rather than treating underreporting as an individual or departmental failure.
The Consequences: When the System Fails to Learn
A fall that goes unreported is not only a missed compliance box—it’s also a lost opportunity for organizational learning.
Each fall, whether resulting in harm or not, provides critical insight into how the components of the system interact with each other. When that data never enters the system, it can’t inform improvement.
As a result, hazards persist, hospitalizations increase, and staff lose confidence that their voices lead to change. Families, in turn, lose trust in the public reporting system.
In systems terms, this represents a broken learning loop, where signals from the frontline fail to reach decision-makers who could act on them.
A Systems Thinking Solution: Aligning the Whole
Transforming fall reporting requires more than a new policy—it requires a redesign of the system that surrounds reporting, learning, and accountability.
Key systems thinking principles can guide this shift:
- True participation: Involve all staff levels in shaping reporting processes. When those who witness events help design the system, reporting becomes practical and meaningful.
- Full integration: Link fall reporting with quality improvement, resident safety, and staffing systems so that data automatically informs action.
- Ongoing learning: Treat every fall or near miss as data for collective improvement, not individual blame.
- Continuous feedback: Validate internal data with external sources (like hospital claims) to maintain accuracy and close the learning loop.
These principles help organizations evolve from a reactive, compliance-driven model to an adaptive system that learns, aligns, and continuously improves.
Building a Just Culture
The path forward begins with leadership that sees the organization as a living system, not a collection of departments, one that evaluates each event with a focus on both individual and organizational accountability.
Creating a just culture means shifting the question solely from “Who failed?” to “What in the system made this choice make sense?” “How can we hold an individual accountable for the choices they make?” and “How can we fix it?”
Practical steps include:
- Ensuring organizational alignment surrounding the response to incidents. This means aligning on what the organization tolerates, recognizes, and rewards, versus what it disciplines.
- Establishing non-punitive reporting policies so staff feel safe sharing incidents.
- Launching “good catch” programs to reward proactive identification of hazards or unsafe conditions.
- Conducting data alignment audits to compare internal MDS data with hospital claims, as recommended by the OIG.
- Reinforcing learning through multidisciplinary review teams that examine patterns across departments.
These efforts turn reporting into a system-strengthening activity—one that fuels improvement instead of fear.
A Call for Systemic Leadership
The OIG’s findings are not just a warning; they’re an invitation to lead differently.
A systems thinking approach recognizes that improving safety data, staff engagement, and resident outcomes are not separate goals—they’re deeply interconnected.
When leaders align incentives, culture, and processes around shared purpose, the system becomes capable of continual improvement.
Reporting incidents honestly doesn’t signal failure. It’s the first step in creating a resilient system that protects residents, supports staff, and earns public trust.
Discover how ECRI’s SafeSystemSM Solutions helps long-term care facilities apply systems thinking to build transparent, learning-oriented safety cultures that protect residents and strengthen organizational integrity.