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Using Six Sigma to Reduce the Utilization of Continuous Observations (1

1) for Safety Precautions

Voetelink, Katherine E. ASQ CSSBB; Trout, Heather B. BSN, RN, PCCN; Murphy, Teresa MSN, RN, NEA-BC; Rogers, Mary MSN, RN, NEA-BC; Harris, Janelle A. MSN, RN, CMSRN, NE-BC; Ramagnano, Sebastian BSN, BS, RN

JONA: The Journal of Nursing Administration: September 2019 - Volume 49 - Issue 9 - p 418–422
doi: 10.1097/NNA.0000000000000778

The need for continuous observation (1:1) of patients for safety precautions, including fall risk, elopement risk, confusion, and aggressive behavior, is highly variable, and it is therefore difficult to plan accurate staffing levels. The high variability in determining when 1:1 staffing for safety is indicated, and for how long, leads to resource strain and high cost to the hospital. A multidisciplinary team analyzed current processes for assigning, monitoring, and discontinuing safety 1:1 care for nonsuicidal patients using Six Sigma methodologies. The team implemented a standardized weaning process to reduce the duration of time on continuous observation and a standardized 4-hour reassessment using a behavior observation-tracking tool to validate the continued need for 1:1 coverage. The interventions resulted in reducing average monthly safety 1:1 staffing hours by 25.6% and saving an estimated $142 000 annually across 6 units. Phase 2 of the project integrated the observation-tracking tool and reassessment check-in into the hospital's electronic medical record for improved tracking and documentation.

Author Affiliations: Lead Performance Improvement Advisor (Ms Voetelink), Operations Improvement; Assistant Nurse Manager (Ms Trout), Staffing for All Seasons; Manager of Nursing Resources and Operations (Ms Murphy), Director of Nursing Operations (Ms Rogers), Department of Nursing; Nurse Manager (Ms Harris) and Nurse Manager of Surgical Intensive Care Unit and Venous Access Team (Mr Ramagnano), Department of Surgical Nursing, Hospital of the University of Pennsylvania, Philadelphia.

The authors declare no conflicts of interest.

Correspondence: Ms Voetelink, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (

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