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Using DMAIC to Improve Nursing Shift-Change Assignments

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 revenue for the past decade.

The American Hospital Association also reported in 2012 that growing labor costs are the most important factor increasing hospital care costs, and found that wages and benefits accounted for more than 59 percent of hospital costs in 2014.

Nurse Shift CS Img1

Wasteful practices must be scrutinized and contained to control hospital staffing costs while maximizing 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 week.

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Using DMAIC to Improve Nursing Shift-Change Assignments

KC Case Study Icon 2-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.

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Nursing Shift-Change Assignments Case Study

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. Nurse Shift CS Img2

This hospital has a formal operational 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.


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 summarizes the metrics by which nursing assignments are produced and shift changes occur.

Nurse Shift CS Fig1

On this particular med-surg unit, there are typically five registered nurses staffing the team. Often the five nurses from the day shift have to interact with each of the five nurses on the night shift as dictated by the patient assignments. If these nurses were to spend less time working on the shift-change nursing report, they could use the extra time to work with their patients, which would have a more direct impact on hospital consumer assessment of healthcare providers and systems (HCAHPS) scores.

One of the key outputs included in Figure 1, HCAHPS, is the mechanism through which patients can rate their medical care experience. Medicare payments to hospitals are, in part, tied to these scores—making them very important.

As designated by the hospital’s parent company, the change of shift report should take no more than 30 minutes. Any report requiring more than 30 minutes was considered a defect. During any shift change, five nurses delivered the report and five received it. Therefore, each report involved an opportunity for five defects.


In order to measure improvement, the team decided to call upon the overall time it took to produce the nursing report. Conclusions were drawn from a total of 30 timed observations. These 30 observations were gathered by the nurse manager and day nurse supervisor.

The pair discretely timed nurses at shift changes in the morning and evening for several weeks. Both observers had a stopwatch function on their smart phone and a form to keep observations accurate and consistent. The observers split the observations evenly for day and night shift changes and both took on observation roles for both shifts.

Due to the busyness or distractions of shift changes, they were not exposed because they would time the nurses from a distance. They were also a routine presence during this time period.

Based on the 30 observations measured, the shift-change nursing report was found to take an average of 43 minutes to complete.

Nurse Shift CS Fig2

The next step was to determine of the 43 minutes, how much accounted for non-value added (NVA) steps. The team determined if the nurses were waiting and not delivering the shift-change report or listening to the report, the time could be categorized as NVA. The value stream map (VSM) in Figure 2 revealed 23 minutes of the process was non-value added and was devoted to completing the shift nursing report as the arriving nurse waited for the previous shift nurse to depart.

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About the Author 

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.

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