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Department: Evidence-based nursing

The only constant is change…make it last with process improvement

Cunning, Shawnna PhD, MSN, CNS, FNP-C

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Nursing Management (Springhouse): April 2014 - Volume 45 - Issue 4 - p 15-17
doi: 10.1097/01.NUMA.0000444880.85439.65
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Healthcare organizations are in a continual state of change. Many factors contribute to the need for changes in healthcare, including technology, government regulations, patient needs, and outcome measures. Resourceful organizations continuously find ways to keep pace with the turbulent nature of the industry by making small, incremental changes based on close analysis of the processes that require improvement.

Over the years, many trends related to this idea have appeared under a variety of titles, including redesign, Lean, and reengineering. These methods have been successful for some organizations, whereas others started but lacked long-term change power, and some never got off the ground due to lack of support, data, or participation. However, these methods are valuable stepping stones in creating process analysis and improvement tools.

In healthcare, continual improvement is essential, and analysis of processes is an effective method to introduce changes to improve the quality of a product or service.

Ask questions

The first step to any improvement project is to determine the global end goal. Is it to enhance quality or customer satisfaction? Reduce costs? Improve a service or decrease time required to perform a task? After the big picture theme is established, specific goals can be determined and metrics established to baseline and trend the goals. This step should include an interdisciplinary team to ensure all stakeholders are accounted for and all repercussions to other departments or service lines are identified before making the change. The use of data in moving a project along to its goal is essential.

There are four steps for improving hospitals' use of data:

  1. Determine metrics. Determining the performance metrics that are valuable to the organization and the project is crucial. If data aren't specific and relevant, they become overwhelming and nonproductive. The metrics also serve as a guide for goals and benchmarks, as well as past performance trends.
  2. Establish the measurement process. After the metrics are identified, there must be a system for measuring the data continuously. Regular, accurate data are the drivers to effective process changes.
  3. Review data daily. Real-time data allow for problem identification and rapid improvements or changes to prevent errors or safety issues. Analysis on a daily basis, or as often as the data can be mined, is effective for keeping the project momentum going and motivating change.
  4. Make data visible. Data visibility keeps everyone aware of ongoing performance in relation to goals and benchmarks. This is particularly important for frontline staff members because visibility prompts them to drive process improvement and take ownership of the changes they wish to create.1

When the goals are established, the legwork of the project begins. Any time a process is analyzed, the actual acts performed by frontline staff should be directly observed. Assumptions or verbal descriptions of processes often fail to reveal the true process and its weaknesses and strengths. One method is to observe staff members performing a process in their actual work environment. If the process is organization-wide, observe staff members in multiple departments and watch for variation, or if it's department specific, observe five different staff members performing the task and document the differences. After differences are established, ask the staff members why they do things the way they do and if they've ever considered other ways of performing the process.

A template should be developed if multiple observers are involved to keep the process uniform. Create a process map of all the steps and account for variation. (See Process improvement resources.) Have the committee analyze the process map and decide on the most effective and efficient way to accomplish the task being analyzed.

A useful tool for analyzing processes in an organization is FOCUS Plan, Do, Check, Act (FOCUS-PDCA):

  • find a process to improve
  • organize a team that knows the process
  • clarify current knowledge of the process
  • understand the variability and capability of the process
  • select a plan for continuous improvement.

PDCA gives the team a cycle to test their improvement strategies one by one in a controlled manner to measure results.2

Create innovative solutions

After the preliminary analysis of processes has been performed, the next step is to implement lasting change. Many techniques for error prevention or standardization of processes have been developed in healthcare. Safety tools, such as checklists, standardized communication terminology and scripting, protocols, and staff huddles, have been utilized to prevent errors and promote patient safety.

A common method is the use of checklists. However, checklists must be used with input from key players and leaders skilled in their proper use. First and foremost, checklists aren't designed to be used as an audit tool. Checklists aren't about creating a paper trail; rather, they're an aid to help the care team crosscheck and verify critical items of a process or procedure. The length of the checklist is vital; not everything has to be on it. Critical items are those that, if not done correctly or omitted, have the potential to cause harm or deviation from best practice.3

Each step should have a goal and a progression, rather than just tasks in a list. This crosscheck by multiple team members creates the needed engagement and mindfulness of multiple sets of eyes during the checklist process, and is much more valuable to overall safety than having checkmarks in the appropriate boxes on a list. A checklist makes it easy to create a false sense of security that a process or task has been completed when it actually hasn't or didn't prompt the next needed process to start.

For example, a restraint checklist may state that an order was obtained and the required patient checks were done. This is a one-dimensional view of one caregiver's tasks for his or her shift. A better checklist outlines the time and reason for the order, when the next order is due, interventions that may have failed, and plans for improvement for the next-shift caregiver. This type of document shows that required tasks were completed and provides communication and direction for future caregivers. Additionally, electronic lists that cue a workflow or task list are more effective because they remove the risk of human error.

Maintain the new environment

Even when effective checklists are created and implemented, they must be updated and refined as needed. In healthcare, tools such as checklists are rarely perfect the first time that they're rolled out. They must be treated as living documents, to be revised and updated as needed by the people utilizing them and doing the tasks controlled by the process.

Every document must also contain the originator's name, a version number, and the date created. This promotes document control and communicates who's responsible for the updating and revising process. Documents for clinical use must be stored electronically for limited retrieval to promote use of the most current version.

After a tool is created, education and communication to frontline staff members must be diligently delivered regarding the proper use of the tool and the desired objective. This is necessary to imbed the tool and the process into the organization's culture.

Become an exemplar

Consider the following example. At a 325-bed community hospital, clinical nurses on a unit-based council theorized that throughput from the ED to the inpatient units wasn't as efficient or timely as it should be. They gathered data about the time from the physician's admission decision to the time that the patient was in the room on the unit, and the times were surprisingly higher than imagined. The council decided to analyze the entire process to find areas for improvement. With managerial and director-level oversight, multiple staff members were deployed to observe processes throughout the patient's journey from the ED to the unit.

Some of the steps in the process that were identified as time gaps included:

  • Communication from the ED to the bed coordinator could take multiple pages and many calls back and forth.
  • The bed coordinator reported time delays in getting rooms cleaned or having beds identified as “next to fill.”
  • Giving report to the inpatient units often took multiple attempts due to nurses being busy or unavailable.
  • Inpatient staff members were uneasy about taking patients when they had other complex patients or multiple admissions due to the time-consuming nature of the admission.
  • Certain times of the day saw an influx of patients and the units weren't prepared to take a high number of admissions at those times.

The group analyzed the issues and discussed solutions. Some of the solutions included having an admission nurse in the ED so that when patients went to the unit, they were already admitted in the electronic medical record. This made multiple admissions to the floor more feasible. The bed coordinator was given an in-house phone to eliminate the time wasting that paging and waiting for a return call caused. The staff members on the units were educated that they were expected to take report when the ED called, or the charge nurse could take report to prevent delays. The change-of-shift process and notification of dirty beds were analyzed by housekeeping and changes were made to get beds cleaned within a tighter timeframe. Staffing patterns in the ED and inpatient areas were also looked at for the possibility of staggering shifts to accommodate the busier admission times.

All of these efforts were beneficial in getting the staff to understand the process and implement changes to decrease throughput times. Staff members felt empowered to improve the patient experience and had the tools and guidance to analyze the processes affecting the desired outcome. In this case, the unit-based process analysis teams were crucial to rolling out the new processes and analyzing the data for improvement.

Hardwire excellence

Process analysis is the tool that hardwires consistent behavior, producing real and measurable change in a healthcare organization. This is the key to process improvement sustainability. Long after the effects of new process roll-out or classroom training have worn off, safety tools will ensure permanent culture change. Continual analysis of data also provides insight about the effectiveness of process changes related to set goals and outcomes.

Process improvement resources

Resources are available to help organize and guide process improvement projects. The Institute for Healthcare Improvement offers free, interactive, web-based improvement maps at You can find a guide to creating process maps at


1. Rodak S.4 steps for improving hospitals' use of data to support Lean initiatives.
2. iSixSigma. FOCUS-PDCA.
3. Harden S.Seven tips to turbo charge your surgical safety checklists.
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