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August 4, 2016

Hitting the Target

6 Tips for Reaching Your Process Improvement Goals

Recently, one of our clients was recognized by CMS for achieving significant decreases in CAUTI rates within its ICU. We sat down with one of our consultants who spearheaded many of the improvements to find out what she did to help this department achieve such successful outcomes. If your facility is looking to make process improvements to achieve specific outcomes, the following steps may prove helpful for getting your team on board, moving in the right direction, and ultimately, crossing the finish line where you want to be.

You may be considering a Process Improvement (PI) initiative for any or all of the following reasons: to improve quality outcomes, increase staff morale, reap financial benefits, repair current operational breakdowns, and/or enhance patient experience and satisfaction. Whatever the impetus for the undertaking, there are six key steps to successfully create and implement a PI initiative:

1. Work to gain buy-in
2. Enable staff to have a successful project
3. Expect obstacles and how to address them
4. Use Standard Work
5. Measure everything
6. Celebrate success

1. Use a Process Driven by Staff Involvement and Derived from a Unit-based Council

Once leadership has identified the goals for the Process Improvement (PI) initiative, begin to integrate front-line staff members into the process. Oftentimes these team members offer a different perspective and understanding of the current state of your department. When empowered to do so, they may offer creative solutions to address those issues. Allowing staff members of all levels to drive process improvement initiatives will help your PI team get to the heart of many major issues.

Breaking your PI team into representatives based on affected units will ensure that all stakeholders are accounted for, and that each group gets a vote on major issues and how to improve them. Therefore, it is imperative to begin your endeavor by creating a team that will collaborate to determine the steps that will most appropriately improve the process at hand. The following are tips for creating and leading your PI team:

  • Compose a team with a representative from each appropriate stakeholder group
    • Include all levels of caregivers
      • E.g., Admissions, Infection Prevention, Staff/RNs in the affected department(s), charge nurses, nurses’ aides
    • Include physicians
      • E.g., the physician may order a Foley catheter, but they have to agree about when to take it out if improving CAUTI rates is your goal
    • Limit your team to seven or fewer people if possible, as it can become increasingly difficult to reach consensus with more than 8-10 people on decision-making team
      • Use subgroups if more than 8-10 representatives are needed
      • Consider the size of the team in relation to the number of staff resources you are utilizing from each stakeholder area

2. Establish a Process that Works for Your Organization

The idea of establishing a process that works for your organization is not so much about establishing the “correct” process as it is about establishing a process that appeals to your organizational culture and the unique setting targeted for improvement.

  • Some process changes may not be possible due to barriers within the organization’s structural, physical, or cultural make-up
  • Develop a functional team 
    • Items for improvement must be achievable and realistic
    • The team must be able to come to a consensus

3. Stick to the Process & Adjust Quickly to Reduce Obstacles

Make sure that all parties involved in the PI initiatives adhere to the process as agreed upon, and do not allow in-the-moment changes to the process. For example, a doctor may not like a new process, so he/she wants to change it in the moment to fit his/hers preferences. While this may seem harmless—especially for smaller items—if every stakeholder changed the processes they did not like, the initiative would fall apart.

Sometimes course corrections may be necessary. Perhaps an idea sounded great on paper, but was not really practical when implemented due to unforeseen variables. In cases where course corrections are needed, vet them through the process improvement team to reinforce structure and avoid implying tolerance of impulsive changes.

4. Have a Standard Work & Standard Operating Procedure

It is important to have a standard of work to provide consistency in service delivery by giving specific, standardized directions for each process. Increasing consistency helps to eliminate errors in the process. Additionally, Standard Operating Procedures (SOP or “job aid”) should be provided for each area so that all employees involved in the process know how the unit/department operates. For example, a nurse who moves from one unit to another may have the skills to work in the new unit, but may be unaware of how that unit conducts processes. Through the SOP, this nurse should be able to understand the work processes of the new unit. If additional guidance is needed, setting up a mentoring system can prove to be an effective option.

5. Measure Everything

Measure everything. The goal of the ICU project mentioned previously was not only to improve all quality metrics, but also to focus specifically on CAUTI reduction and to sustain previous gains with CLABSI reductions. While measuring everything allows you to track improvements, it will also allow you to verify that your efforts are not impeding previous advancements.

With the goal of preventing additional infections and taking care of the immediate needs of all patients, the following are some items our team measured to validate its achievements for this ICU-specific project:

  • Foley catheter use
    • Use rates, including time used
    • Infection rates
  • CLABSI rates
  • Pressure ulcers
  • Staffing
    • Ensure that department/unit is appropriately staffed to meet needs
  • Staff satisfaction
  • Patient Satisfaction


In order for the project to be successful, it is necessary to set specific, realistic goals before beginning work. Base these goals on current metrics and determine where you want to see the metrics in a defined amount of time. The following are two sample goals that were set for this project to help our consultants determine whether the desired improvements were being made:

  • Decrease Foley Catheter Utilization from 70th to 60th percentile of NHSN utilization
  • Decrease hospital-acquired pressure ulcers in the ICU by 75 percent from the current percentage

6. Celebrate Success

Following any success or milestone, acknowledge your PI team and other staff members for their hard work. The significance of the success may dictate the type of recognition that is most appropriate. For smaller accomplishments, a verbal appreciation may be sufficient (e.g., recognizing individuals’ successes at daily stand up board or daily huddles), but larger accomplishments may be more fitting for lunch, desserts, or a special event. The main goal here is to let your PI team and affected stakeholders know that you appreciate their efforts. When administration shows appreciation to staff members, it can boost morale significantly and may help improve cooperation for future projects.

Next Steps

Are you interested in learning more about how to make improvements at the unit, department, or organization level? Soyring’s consultants are experienced with developing and implementing process improvement teams and quality improvement initiatives. Contact us today to learn more about how Soyring Consulting can assist with your process improvement needs, whether they address immediate or projected concerns.

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