Making the Case for Quality
February 2016
Using DMAIC to Improve
Nursing Shift-Change Assignments
At a Glance . . .
• In this case study involving
an anonymous hospital,
nursing department
leaders sought to improve
efficiency of their staff’s
shift change assignments.
• Upon value stream
mapping the process,
team members identified
the shift nursing report
took 43 minutes on
average to complete.
• Using DMAIC and
other quality tools, team
members improved the
process’ sigma level
from 0.7 to 3.3.
ASQ www.asq.org Page 1 of 6
by Casey Hewes and Nina Costilla BSN, RN
Labor represents the largest expense for large metropolitan hospitals by far. According to Becker’s
Hospital CFO newsletter, labor costs have typically averaged 50 percent of hospitals’ total operating
revenue1 for the past decade. The American Hospital Association also reported in 2012 that growing
labor costs are the most important factor increasing hospital care costs2, and found that wages and ben-
efits accounted for more than 59 percent of hospital costs in 20143.
Wasteful practices must be scrutinized and contained to control hospital staffing costs while maxi-
mizing operational efficiency. One area of opportunity involves the shift changes for nursing staff, a
process that too frequently results in nurses staying later than their scheduled departure time. In 2010
the U.S. Department of Health and Human Services reported 54 percent of registered nurses surveyed
said they worked more than 39 hours per week4.
A 600-bed hospital near Dallas, TX, initiated a project to improve its nursing shift change process to
cut labor costs without negatively affecting the quality of patient care. This hospital has a formal opera-
tional excellence department that primarily uses Lean Six Sigma methodology, following the define,
measure, analyze, improve, control (DMAIC) approach. The project was approved and facilitated by
this department as well as the service line director of nursing.
Working with Mark J. Davis, a Lean Six Sigma Black Belt as their mentor, the nurse manager and day
nurse supervisor for a medicine and surgery (med-surg) unit led the project. The DMAIC approach
helped the team uncover solutions that would allow nurses to leave work on time and encourage
greater efficiency in the shift-change process.
Define
The shift-change nursing report is the primary tool used to ensure continuity of care as staff change
happens every 12 hours. The report contains pertinent patient information, and is given to the arriving
nurse before the previous nurse on duty leaves at the end of a shift. Nursing assignments are given to
the arriving nurse, and include the list of patients they are to care for.
The charge nurse is responsible for making these assignments, which are typically subjective and based
on many variables (patient acuity, blood sugar levels, and proximity to the nursing station, along with
overall scheduling for the nursing floor, such as number of admissions and discharges, etc.).
The SIPOC map in Figure 1 sum-
marizes the metrics by which nursing Figure 1: SIPOC map for shift changes
assignments are produced and shift
changes occur. Supplier Inputs Process Outputs Customers
• Staff • Staff • Time • Service Line
On this particular med-surg unit, there Staff Put away
• HCAHPS Director
punch in belongings
are typically five registered nurses • Employee • Leadership
staffing the team. Often the five nurses Satisfaction • Staff
Find 1 RN Get • Salary • Patients
from the day shift have to interact with get report assignments
each of the five nurses on the night • FTEs
shift as dictated by the patient assign- Find 2 RN Find 3 RN
ments. If these nurses were to spend get report get report
less time working on the shift-change
nursing report, they could use the extra Find 5 RN Find 4 RN
time to work with their patients, which get report get report
would have a more direct impact
Providers Resources Top-level description of the activity Deliverables Anyone who
on hospital consumer assessment of the required from the receives a
of healthcare providers and systems required by the process deliverable from
(HCAHPS) scores. One of the key out- resources process the process
puts included in Figure 1, HCAHPS, is
the mechanism through which patients day and night shift changes and both took on observation roles for both shifts. Due to the
can rate their medical care experience. busyness or distractions of shift changes, they were not exposed because they would time
Medicare payments to hospitals are, the nurses from a distance. They were also a routine presence during this time period.
in part, tied to these scores—making
Based on the 30 observations measured, the shift-change nursing report was found to take
them very important.
an average of 43 minutes to complete.
As designated by the hospital’s parent
The next step was to determine of the 43 minutes, how much accounted for nonvalue-
company, the change of shift report
added (NVA) steps. The team determined if the nurses were waiting and not delivering
should take no more than 30 min-
the shift-change report or listening to the report, the time could be categorized as NVA.
utes. Any report requiring more than
30 minutes was considered a defect. The value stream map (VSM) in Figure 2 revealed 23 minutes of the process was non-
During any shift change, five nurses value added and was devoted to completing the shift nursing report as the arriving nurse
delivered the report and five received waited for the previous shift nurse to depart. The oncoming nurse waited to receive
it. Therefore, each report involved an
opportunity for five defects.
Figure 2: VSM for shift change reports
Measure
Staff I Put away I Get
In order to measure improvement, the punch in belongings assignment
team decided to call upon the overall 10 seconds 2 minutes
CT=10 sec (Transaction 1) CT=2 min (Transaction 2) CT=10 sec I
time it took to produce the nursing CVA=0 CVA=0 CVA=0
BNVA=10 sec BNVA=0 BNVA=10 sec 5 minutes
report. Conclusions were drawn from a NVA=0 NVA=0 NVA=0 (Transaction 3)
total of 30 timed observations. These 30
observations were gathered by the nurse
manager and day nurse supervisor. Report with I Report with I Report with
nurse 3 nurse 2 nurse 1
5 minutes 5 minutes
The pair discretely timed nurses at shift CT=6 min (Transaction 5) CT=6 min (Transaction 4) CT=7 min
CVA=6 min CVA=6 min CVA=7 min
changes in the morning and evening BNVA=0 BNVA=0 BNVA=0
for several weeks. Both observers had NVA=0 NVA=0 NVA=0

a stopwatch function on their smart

phone and a form to keep observations
accurate and consistent. The observ-
ers split the observations evenly for
Total lead time = 43 minutes Note: Three nurses are
Process time = 23 minutes in the value stream map
Total NVA = 20 minutes because that is the average.

ASQ www.asq.org Page 2 of 6

reports from an average of three departing nurses before she
could begin her duties.
Analyze
To begin addressing potential solutions for NVA wait time, the
team completed a failure mode and effects analysis (FMEA)
chart (see Table 1). This analysis is a complete and quantified
cause and effect chart that pinpoints potential reasons why the
shift-change report is taking so long to complete. Included in the
FMEA is a risk priority number, which suggests the factors that
should take the highest priority in promoting change.
The following are the steps for completing the FMEA:
1. Analyze what may be causing a long nursing report.
• For example, the number of nurses involved will
influence the length of the report.

Table 1 — FMEA to identify reasons for NVA steps

Process or Staff Nurses Report Disection Prepared by: Page _1_ of _1_
Product Name: Nina Costilla, Casey Hewes
Responsible: Project Team FMEA Date (Orig) 5/16/2015   (Rev) ____________
Process Step/ Potential Potential Potential Causes Current Actions Responsible
Input Failure Mode Failure Effects Controls Recommended
What is the In what ways What is the impact? What causes the What are What are the

Occurrence

Detection
Severity
process step does the process process step or the existing R actions for
or input? step or input input to go wrong? controls and P reducing the
go wrong? procedures that N occurrence
prevent either of the cause,
the cause or the or improving
failure mode? detection?
Amount of Too many staff Delay in report Charge nurse None Territories Casey/Nina
nurses nurses to give because have to assignment
8 10 9 720
report to wait for or find
next staff nurse
PCTs in report Timing of PCT Distracted PCTs and Change of None Stagger Casey
in report staff nurses respond 6 shift design 10 10 600 ongoing/
to call lights outgoing staff
Standardization Report is given Varied time Different staff nurses Potential to Standardization Laurie
based on staff of report have different skill offput offgoing/ of report Robbins
7 10 8 560
nurse preference levels and areas ongoing nurse
of emphasis
Charge in Timing of charge Distracted charge Change of None Stagger Casey
report nurse in report nurses and staff shift design ongoing/
5 10 10 500
nurses respond outgoing staff
to call lights
Rapport vs. Relationship Delay in report Nurses choice Potential to Education on Casey
report development offput offgoing communication
5 8 5 200
versus actual nurse style
report
Layout – Hamon has Less walking Lack of satellite None Build out Casey/Nina
Hamon vs. nooks or areas for nurses Medication Pyxis. 615 and
Main for nurses to Less nooks. create nook
3 10 5 150
watch their
pod and more
Medication Pyxis
CareConnect CareConnect Inefficient report CareConnect Ability to Choice to use Debbie Van
inefficient report not and delay in report decision work around CareConnect Sickel/Super
5 5 5 125
optimized CareConnect or not user/Laurie
Robbins
Not enough Each staff nurse Delay in report Can’t use Adequate Keep WOWs Night
WOWs uses WOW CareConnect amount of operational charge
3 4 10 120
for report report or unable WOWs nurses
to bedside report
FTE/OT/Salary Doesn’t directly Does not measure Don’t utilize N/A Casey
measure precisely 2 N/A 1 report 1 2
report time
Clock in/ Doesn’t directly Does not measure Don’t utilize N/A Casey
clock out measure precisely 2 N/A 1 report 1 2
report time

ASQ www.asq.org Page 3 of 6

2. Identify how the step can go wrong.
• Too many nurses may be giving the report to each other
at the same time.
3. Identify what impact the step has on the nursing report.
• The problem is when there are so many nurses they have
to wait for each other.
4. Determine potential causes for the problem.
• The cause of this problem is that the way assignments are
done, nurses must give the report to several other nurses.
5. Assess potential controls that exist for the problem.
• There are no controls in place to manage this problem.
6. Identify how to reduce the likelihood of the problem.
• Create assignments where one nurse can give the report
to only one other nurse.
most significant and controllable source of unnecessary payroll
expenditures existed in the number of nurses involved in pro-
ducing the shift-change reports.
Typically, this unit runs over budget by approximately $5,000
per month in payroll expenditures. This process most likely
exists for the majority of hospital units across the United States
because it has always been done this way.
In order to operate more efficiently in the reporting process, the
team redesigned the layout so the nursing assignments are del-
egated in clusters or by an emphasis on geography. By dividing
assignments by territory, the team was able to maintain flexibil-
ity while relegating assignments to a specific area.

Improve Unit staff were presented with two solutions: “territory” or

“pods.” As the force field analysis in Figure 3 illustrates, ter-
Upon observing and analyzing the data, the team identified a ritory allowed more flexibility, and pods were very simple.
key area for most effectively eliminating waste. It was clear the Territories are more flexible because there is a range the nurses

Figure 3: Force field analysis of potential solutions, territory vs. pods

Main 6 West – Geographic Assignment 3 Territory #1 will be the charge assignment

since there are nine rooms.
If night is four nurses, three
Staff Stairs rooms from #3 go to #1 and
Boardroom 625 624 623 622 621 Slower
Elevators two rooms from #3 go to #2.
5 Flexibility assignments 2
2a 2b
Storage
Offices

Room

Guest Nurse’s
Pyxis

Med

620 619 618 617 616 615

Elevators Station
Confusing/
2 Our own Interpretation 1

Waiting
601 602 603 604 605 606 607 608 609 610 611 612 614
Room

1a 1b 2a 2b
7 3
Scale importance
- Balanced acuity - Proximity 1 = Less importance 5 = More importance
- Continuity - Speed/Ease of
of care assignments

5 Pods Pod #2 is charge assignment.

If night is four nurses,
will split pod #2.
2
Stairs

3 Easy Staff
Boardroom 625 624 623 622 621 Inflexibility
Elevators

4
Storage
Offices

Room

Guest Nurse’s
Pyxis

Med

620 619 618 617 616 615

Elevators Station
Charge
2
Can’t assignment
1 complain will be difficult
Waiting
601 602 603 604 605 606 607 608 609 610 611 612 614
Room

4 1 2 3 4

ASQ www.asq.org Page 4 of 6

can be assigned, but the range is greatly
reduced from the previous scenario.
Pods are more rigid and straightforward
because a nurse has a predetermined
set range, i.e., beds 1-5 with no room
for flexibility. The territory assignment
began January 1 at midnight.

Control

The team tested the territory nurs-

ing assignment methodology during
a 30-day trial period for both shifts
on the med-surg unit in question, and
the results were extremely favorable.
Under the territory framework, any
given nurse will average one nurse,
two at the maximum, to whom they
must provide their shift change report.

To deploy the process change, com-

munications were dispersed to all unit
staff through informal discussions, Figure 4: Future state VSM (post-intervention)
emails, and in a staff meeting featuring
extensive dialogue. Extra communi-
cation and Q&A talking points were Staff I Put away I Get
punch in belongings assignment
provided for the charge nurses. 10 seconds 2 minutes
CT=10 sec (Transaction 1) CT=2 min (Transaction 2) CT=10 sec I
CVA=0 CVA=0 CVA=0
Upon implementation of the new BNVA=10 sec BNVA=0 BNVA=10 sec 3 minutes
process, the average time it took to NVA=0 NVA=0 NVA=0 (Transaction 3)

complete the report now stood at 30

minutes, thereby reducing needless
waiting times significantly. Figure 4 Report with
nurse 1
illustrates the VSM for the improved
process while Table 2 shows the sigma Total lead time = 30 minutes CT=25 min
CVA=25 min
Process time = 25 minutes
level for the process improved from BNVA=0
Total NVA = 5 minutes NVA=0
0.7 to 3.3.

Table 2 — Process improvement as measured by sigma level

Pre-Intervention Post-Intervention
The calculation of a sigma level, is based on the number The calculation of a sigma level, is based on the number
of defects per million opportunities (DPMO). of defects per million opportunities (DPMO).
In order to calculate the DPMO, three distinct In order to calculate the DPMO, three distinct
pieces of information are required: pieces of information are required:
a) the number of handoffs produced Opportunity a) the number of handoffs produced Opportunity
b) the number of defect opportunities per handoff Defect/Opportunity b) the number of defect opportunities per handoff Defect/Opportunity
c) the number of defects Defect c) the number of defects Defect
The actual formula is: The actual formula is:
(Number of defects x 1,000,000) (Number of defects x 1,000,000)
DPMO = DPMO =
((Number of defect opportunities/unit) x number of units) ((Number of defect opportunities/unit) x number of units)
Defects = 24 DPMO = 800,000 Defects = 1 DPMO = 33,333.33
Opportunities = 30 Sigma level = 0.7 Opportunities = 30 Sigma level = 3.3
Defect opportunities per unit = 1 (Max sigma level = 6.0) Defect opportunities per unit = 1 (Max sigma level = 6.0)

ASQ www.asq.org Page 5 of 6

Figure 5: Goal achievement graphs
Med-Surg Unit flex and productive FTE
44
42
40
38
36
34
32
Flex Productive FTE
30
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
The goal achievement graph in Figure 5
reflects a greater efficiency and produc-
tivity as a result of process change. The
nurses have also had a great experience
and favor the new change, as some have
particularly noted they are walking less
throughout the day and delivering their
reports more quickly.
The x-axis in Figure 5 represents produc-
tivity and is used by the nurse manager
to evaluate labor utilization. The blue
line represents how many employees
the finance department thinks should be
required, given the census, and the red
line is the actual amount used. To date,
the improvement has been in place for
six months and is self-sustaining.
There have been no interventions by the
nurse manager or day shift supervisor.
There have been discussions rolling this
program out to other med-surg units, but
this has yet to be executed. Currently,
there are no other plans or discussions to
improve this process.
Clearly, there is room for greater effi-
ciency among the majority of hospitals
across the country. This case study
demonstrates an opportunity for similar
ASQ www.asq.org Page 6 of 6
Productive FTE
units to emulate since it could address
an industry-wide problem. If other
med-surg units took this shift-change
project on and it became the norm,
versus an outlier, we could positively
affect healthcare costs.
References
1. Bob Herman, “10 Statistics on
Hospital Labor Costs as a Percentage
of Operating Revenue,” Hospital
CFO, December 10, 2013, www.
beckershospitalreview.com/
finance/10-statistics-on-hospital-
labor-costs-as-a-percentage-of-
operating-revenue.html.
2. American Hospital Association,
“The Cost of Caring,” AHA.org,
June 2012, www.aha.org/content/12/
CostofCaring2012.pdf.
3. American Hospital Association,
“TrendWatch: Chartbook 2015,”
AHA.org, 2015, www.aha.org/
research/reports/tw/chartbook/
index.shtml.
4. Sung-Heui Bae, “Nursing Overtime:
Why, How Much, and Under What
Working Conditions?,” Nursing
Economics, March-April 2012.
For More Information
• To contact the author of this case
study, email Casey Hewes at
CaseyHewes@Outlook.com.
• To view this and other case studies,
visit the ASQ Knowledge Center at
asq.org/knowledge-center/
case-studies.
About the Authors
Casey Hewes has worked in healthcare
for 12 years as a staff nurse and in
management. He has a master’s degree
in business administration with an
emphasis in finance from the University
of Hawaii.
Nina Costilla, a native Texan, received
her bachelor’s degree in nursing from
Texas Tech University. She is currently
working toward a master’s degree in
nursing from Texas Tech.