How the Falls and Fragility Fracture Audit Programme improves quality

11 Feb 2019

11 Feb 2019

With an ageing population, preventing falls and fragility fractures is more important than ever, writes Falls and Fragility Fracture Audit Programme project manager Bonnie Wiles.

Older people are not only more likely to fall, but as a result they suffer severe consequences, such as loss of confidence and loss of independence, which can lead to mental and physical deterioration, increasing the risk of further falls and fractures and therefore increasing the risk of death.

In 2017 65,958 people presented with a hip fracture. Hip fracture is the most serious common injury in older people. It is the most common reason for older people to need emergency surgery and the most common cause of death following an accident. The care provided to people with hip fractures provides an unparalleled example of how frail and older people are managed by the modern NHS.

The Falls and Fragility Fracture Audit Programme (FFFAP) is a clinically-led suite of national clinical audits commissioned by the Healthcare Quality Improvement Partnership (HQIP) and run by the RCP. The team delivers large, complex audits and quality improvement work which have considerable impact.

The current programme embeds quality improvement throughout the structure of these audits which focus on the care that patients with fragility fractures receive in hospitals and those who suffer a fall while an inpatient in England and Wales.

The care that patients receive is measured through three linked national clinical audits:

  1. The National Hip Fracture Database (NHFD) – The NHFD collects data on the processes and outcomes for all patients admitted to hospital with hip fractures. 100% of acute services in England and Wales participate. The NHFD has over half a million records making it the largest hip fracture database in the world.
  2. The Fracture Liaison Service Database (FLS-DB) – Fracture Liaison Services are secondary fracture prevention services which aim to ensure patients presenting with fragility fractures receive fracture
    risk assessment and treatment where appropriate. The FLS-DB audits the care provided to patients with a fragility fracture or who have accessed a fracture liaison service and evaluate patterns of assessment and treatment in England and Wales.
  3. The National Audit of Inpatient Falls (NAIF) – This new continuous audit started in January 2019, previously running as snapshot audits. NAIF focuses on patients who fall in hospital, resulting in a hip fracture. Hip fractures were used as an example of serious harm resulting from a fall; the audit aims to drive improvement for the wider population of patients that suffer a fall.

How we work with patients

A key aim for the work is to engage patients, carers and families in a meaningful way to achieve a strong patient voice which informs and contributes to the design and direction of the work. The team has produced a range of patient-focused outputs. These include:

> My Hip Fracture Care, a guide book for patients, their families and carers. Produced from the results of the NHFD in 2015.

> Falls Prevention in Hospital: a Guide for Patients, their Families and Carers, to help prevent serious injury and unnecessary cost to the NHS caused by older people falling when in hospital.

> Strong Bones After 50, an animation and lea et on secondary fracture prevention, providing a jargon-free explanation for patients and carers on fragility fractures and what to expect from their care.

A patient panel was established in 2018 in collaboration with the Royal Osteoporosis Society. The panel is composed of patients and carers with experience of fractures, osteoporosis and falls. The patient panel meets twice annually and provides feedback and input on all aspects of the programme.

How we support clinical teams with improving care

FFFAP has been developed to have maximum impact in the improvement of quality of services. Examples of this include:

> the development of work to improve the participation of trainees in the delivery of local quality improvement work based on data collected by the audit

> signposting audit participants to quality improvement relevant initiatives and tools such as the vision assessment, slide sets, videos and collaboratives

> all three of the workstreams have been used in the NICE impact report on falls and fragility fractures to demonstrate changes in patient care and highlighting opportunities for national change and further improvements.

To support local improvement all three audit workstreams publish annual reports to guide participants and commissioners. Further to this, the NHFD and FLSDB have public run charts and interactive data dashboards available ( These facilitate local teams to use real-time data from the audit, updated hourly, to drive and shape local improvement by enabling them to examine common and special causes of variation in performance.

Plans in 2019

We will be making dynamic data available on the webtool, including locally customisable reporting tools, such as pivot tables (

We are also running a 9-month QI course led by RCP Quality Improvement for teams working in secondary fracture prevention, and you can read more about this on the next page. For more information about FFFAP visit:
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