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Ninety to
Ninety to Nothing: a PDSA quality Nothing
improvement project
Gayle Linda Prybutok
University of North Texas, Denton, Texas, USA
361
Abstract Received 4 June 2017
Purpose – The purpose of this paper is to present a case study of a successful quality improvement project in Revised 28 July 2017
an acute care hospital focused on reducing the time of the total patient visit in the emergency department. Accepted 25 September 2017
Design/methodology/approach – A multidisciplinary quality improvement team, using the PDSA
(Plan, Do, Study, Act) Cycle, analyzed the emergency department care delivery process and sequentially made
process improvements that contributed to project success.
Findings – The average turnaround time goal of 90 minutes or less per visit was achieved in four months,
and the organization enjoyed significant collateral benefits both internal to the organization and for its
customers.
Practical implications – This successful PDSA process can be duplicated by healthcare organizations of
all sizes seeking to improve a process related to timely, high-quality patient care delivery.
Originality/value – Extended wait time in hospital emergency departments is a universal problem in the
USA that reduces the quality of the customer experience and that delays necessary patient care. This case
study demonstrates that a structured quality improvement process implemented by a multidisciplinary team
with the authority to make necessary process changes can successfully redefine the norm.
Keywords Efficiency, Process redesign, Service delivery, PDSA, Service quality,
Continuous quality improvement,
Paper type Case study

Introduction
The US Agency for Healthcare Research and Quality (2003) has defined the parameters of
quality healthcare as “doing the right thing, at the right time, in the right way, for the right
person, and having the best possible results”. For years, patients seen in hospital emergency
rooms have endured inordinately long wait times, poor communication with clinicians, and
substandard customer service during a medical crisis, believing that this was the norm.
This is the story of a hospital that changed the paradigm using the PDSA Cycle proposed by
Deming (1982), and that created process improvements that would reduce turnaround time
in the hospital emergency room no matter what the size of the population served.

A targeted quality improvement project

This paper describes a highly successful quality improvement project with the goal of
reducing turnaround time in the emergency department of a 60-bed community hospital
located in North Texas. For this project, the team defined turnaround time as the total
amount of time between the time the patient signs in to the emergency room to the time that
the patient is discharged. One of the important contributions of this work is that it shows
how cultural issues in healthcare practice can be addressed using a structured quality
improvement problem-solving approach. The PDSA cycle is well accepted in many
manufacturing and for-profit service environments, and many of those organizations have
moved into six sigma and lean processes. However, the acceptance of such common quality
improvement approaches is less common in non-profit healthcare organizations and much
International Journal of Health
can be learned by examining what worked and why in this unique success story. At the time Care Quality Assurance
of the project’s initiation, this rural community hospital was not only facing competition Vol. 31 No. 4, 2018
pp. 361-372
from a variety of local provider organizations, but also was undergoing a cultural shift and a © Emerald Publishing Limited
0952-6862
change in the organizational mission and vision driven by a new CEO. DOI 10.1108/IJHCQA-06-2017-0093
IJHCQA The hospital and its place in the community
31,4 The Medical Center is in a small north Texas community that is the County Seat and that
had a population of 16,095 in 2014 per City-Data.com (www.city-data.com/city/) (Table I).
These statistics are relevant because they partially explain the community’s willingness
to accept the extended wait times in the local emergency room. Community members rarely
left the local service area to seek primary healthcare and put their faith in local physicians
362 that had privileges at the Medical Center.
The Medical Center is the only hospital in the community, and it is located 60 miles
outside of a major metropolitan city. There are six nursing homes, one home health agency,
and a dialysis center. The Medical Center is a hospital district, which is a governmental
entity. A nine-member board of directors elected by the registered voters of the hospital
district governs it. Board members serve staggered three-year terms without compensation.
Public Hospital Districts are community-created, governmental entities authorized by state
law to deliver health services to district residents and others in the districts’ service areas.
Most of the revenue received by public hospital districts comes from private and public
insurance. Such hospital districts have legally limited access to property tax dollars but
these tax dollars represent a very small proportion of their total revenue. Since public
hospital districts are governmental entities, they are subject to all state laws related to open
government, and transparency in the conduct of business including the Open Public
Meetings Act, the Public Records Act, etc.
As a healthcare entity, the Medical Center offered the following services:
• 40 general medical/surgical beds;
• six bed intensive care unit;
• 14-bed obstetrics suite with four labor and delivery rooms;
• ten post-partum beds and a newborn nursery;
• in-house surgical services department that also offered outpatient surgery;
• inpatient and outpatient cardiac and physical rehabilitation services;
• 11-bed emergency department certified as a Level IV trauma center;
• in-house pharmacy;

Race Employment Educational background

Caucasian Manufacturing High School Diploma

61.1% 18% 79.5%
Hispanic Construction Bachelor’s Degree
28.7% 11% 14.5%
Black Mining, quarrying and gas extraction Graduate or professional degree
5.1% 10% 3.2%
Biracial Arts, entertainment and recreation
2.2% 8%
Asian Retail
0.7% 8%
American Indian Accommodations, food service
0.1% 7%
Healthcare, social assistance
Table I. 6%
Community Notes: Unemployment rate: 7.3 percent; median household income $40,842; 22.2 percent of the population
demographics living in poverty
 • laboratory; Ninety to
• X-ray department; Nothing
• medical records department;
• patient financial services department;
• materials management department;
363
• hospital-based home health agency; and
• professional office building.
In addition, the Medical Center offered swing bed rehabilitation services in designated
rooms on the Medical and Surgical units licensed and certified separately by the state within
the Medical Center.
At the time of the project, the chief nursing officer had been at the hospital about a year
when there was a change in leadership at the direction of the hospital board. An interim
CEO was hired, and he came with years of experience managing large hospital systems,
including a premier local hospital at which the chief nursing officer had worked in the past.
Because of their prior work at the highly regarded medical center, the CEO and the CNO had
a common frame of reference about quality improvement, and service delivery within the
framework of Joint Commission accreditation (Prybutok and Spink, 1999). With the new
CEO came a new vision for the Medical Center. His vision for the organization included:
a culture of “can do” customer service. He proposed an expansion of the medical center from
60 beds to 100, the addition of an invasive cardiology service line, recruitment of a variety of
specialty physicians, and he set a goal of accreditation by the Joint Commission for the
coming year. When he arrived, the hospital was administering and scoring their own home
grown patient satisfaction surveys. Patients were afraid to answer questions honestly
because many of the caregivers employed at the hospital lived in the community and
patients were often readmitted. Patients were concerned that surveys were not anonymous
and that negative comments would offend staff that would later care for them. Instead, the
CEO contracted with an outside, national organization, Press Ganey, to conduct patient
satisfaction surveys. Surveys were standardized, mailed to the patients’ homes after
discharge, and Press Ganey compared the hospital’s results with other hospitals of similar
size and clinical scope to demonstrate the hospital’s standing among competitors in the eyes
of consumers.

The business environment

Like other hospitals at the time, the Medical Center faced several challenges.
Reimbursement decreased, and depended on the ability to demonstrate quality outcomes.
The Medical Center faced stiff competition in the marketplace for staff, physicians, and
patients. The Medical Center had a large employee base with a high turnover rate, which led
to high orientation and training costs. The risk of litigation was ever-present, and in general,
the cost of doing business was high. Medical supplies expired and replacement was routine
expense; medical equipment was costly and maintenance costs were high, and the cost of
the proposed expansion was significant. It was clear the Medical Center would have to
increase its market share by distinguishing the quality of service delivery.

Literature review
The realities of healthcare quality and patient loyalty
Varkey et al. (2007) reported that the Agency for Healthcare Research and Quality defined
quality as taking the right action, at the proper time, in the correct way, for the right person-and
IJHCQA having the best possible outcome. As reported by Carson (2008), only 4 percent of dissatisfied
31,4 customers voice their complaints, and they are twice as likely to complain about an
unsatisfactory customer service experience than to praise a good experience. In a competitive
market, customer loyalty is key. In the healthcare arena, customers typically do not have the
clinical expertise to assess whether the care that they receive is high quality. Instead, they
evaluate the quality of service based on their perceptions during their care experience.
364
Service quality indicators in healthcare
A variety of studies have been done to identify the most important indicators of quality care
to consumers. In 2000, Oermann and Templin (2000) identified the five most important
indicators of nursing care quality to patients. These were:
(1) Is the nurse up to date and well informed?
(2) Can the patient communicate with the nurse?
(3) Can the patient spend time with the nurse without feeling rushed?
(4) Does the nurse teach the patient about his illness, his medications, and about how to
stay healthy?
(5) Can the patient call the nurse with questions when necessary?
Blizzard (2004) described patient loyalty as being the result of patient satisfaction (which is
a combination of satisfaction with both people and process) and quality. Blizzard identified
drivers of patient loyalty in the inpatient and outpatient areas, in the areas of inpatient tests
and treatment, and in the emergency department. In the emergency department, where
patients are coping with unexpected and potentially urgent care needs, Blizzard pointed to
six correlates of patient loyalty:
(1) Could the patient access help at any time?
(2) Did the staff demonstrate a sense of urgency?
(3) Did the emergency department function efficiently?
(4) Did the staff show concern?
(5) Was care provided in a reasonable amount of time?
(6) Was the patient’s pain managed effectively?
Many of the indicators provided above highlight the importance of blending clinical
expertise with hospitality. Typically, hospitality is not a term associated with a visit to the
emergency room. However, Lee (2004), in his book If Disney Ran Your Hospital-9 ½ Things
You Would Do Differently, emphasized that, in every patient interaction, the healthcare
provider’s goal should be to improve patient satisfaction, and ultimately, patient loyalty.
Further, he made two important points. First, providers should recognize that their
competition in the marketplace was not who they think it is but rather, who the patient
compares them to. Fred reported that patients evaluate their care experiences by the way
they are treated as a person, and so, the goal during each patient encounter is to improve the
patient’s perception of his care experience.

The emergency department at the Medical Center

At the time of this project, the emergency department at the Medical Center was a
high-visibility clinical area, which had a visit volume of 1,500-1,800 visits per month.
The emergency department was certified by the Texas Department of Health and Human
Services as a Level 4 or basic trauma center, capable of caring for or stabilizing all major and
severe trauma patients 24 hours per day for transport to other facilities when resources Ninety to
needed by the trauma patient are not available on site. The emergency department Nothing
physicians, including the medical director of the emergency department, were staffed
through a contract with a physician staffing organization that provided hospitalists and
emergency department physicians to facilities in the local area. All other staff in the
department and throughout the hospital were employed by the Medical Center.
365
Statement of the problem
The chief nursing officer, who was responsible for the emergency department, was charged
with reducing emergency department turnaround time by 30 percent by the new CEO.
For this project, turnaround time was defined as the total amount of time between the time
the patient signed in to the emergency room to the time that the patient was discharged.
At the time the average turnaround time in the emergency department was 126.92 minutes,
which the staff believed was well below the local average. That meant that the target
average turnaround time in the emergency department was 90 minutes or less.
Moreover, hospitality, in addition to the improvement of clinical processes, would have to
be part of the quality improvement initiative. The chief nursing officer identified 11 priority
behaviors that staff would have to adopt during the quality improvement process.
Addressing this initiative represented a culture change that required the emergency
department staff to:
(1) be cheerful and empathetic during interactions with patients;
(2) actively solicit patient needs;
(3) show concern for patient privacy;
(4) brief patients often on the status of their condition, test delays and test results;
(5) explain treatments and medications, and encourage patients to ask questions;
(6) take an active interest in family members and caregivers that come with the patient;
(7) include family and caregivers in the treatment plan at the patient’s request;
(8) communicate with those in the waiting room regularly;
(9) be given the power to diffuse anger and offer a remedy on the spot, without waiting
for a supervisor to address the situation;
(10) work cooperatively with other hospital departments to expedite patient care; and
(11) gain the cooperation of inpatient staff and hospital physicians to achieve turnaround
time target.

The use of PDSA to facilitate quality improvement in healthcare organizations

Nadeem et al. (2013) did a comprehensive literature review on healthcare quality improvement
projects. They reported that in 2001, the Institute of Medicine published Crossing the Quality
Chasm, which stressed the need to improve healthcare quality through use of evidence based
techniques and practices. In 2003, the Institute for Healthcare Improvement developed the
Breakthrough Series Collaborative (BTS) to foster fast and measurable improvements that are
sustainable. BTS applies quality improvement processes to the routine tasks and work flows
of the quality improvement team, and is a four-stage technique. First, a planning group forms
and identifies the project objectives and areas that need to be changed. Next, in the pre-work
stage, team members are selected, roles are identified, and the critical support items are
collected. Then, participants are trained in the quality improvement process and establish
IJHCQA important communication and reporting structures. Finally, the PDSA cycles begin, and the
31,4 team identifies and implements specific interventions, and then assess the results. Similarly,
Schouten et al. (2010) specified four core quality improvement processes: adequate support
from an expert team, strong multidisciplinary teamwork, the use of a quality improvement
model, and effective collaboration.
Berwick (1996) identified PDSA as one of the primary and most effective models used to
366 facilitate change in healthcare settings. Bohnenkamp et al. (2014) reported on the success of
an interdisciplinary team that used PDSA to improve staff compliance with the application
of sequential compression devices. The quality improvement team not only was able to
make changes at the bedside to improve patient outcomes but learned to focus on improving
the system of care without blaming individuals. Tan et al. (2016) reported on the use of
PDSA in a Cancer Genetics clinic that resulted in a 350 percent increase in clinic capacity
while decreasing the cost of patient care. Both the literature review and the examples
provided demonstrated that PDSA has been used successfully in a variety of clinical
settings to improve clinical processes, quality of care, and patient satisfaction.
To achieve the level of culture change required to reduce the emergency department
turnaround time, a multidisciplinary, team-based PDSA quality improvement process was
selected to guide the management team and staff through a structured improvement
approach. While the hospital had other options that were presented by expert faculty at a local
university who had years of quality improvement consulting experience, the chief nursing
officer selected the PDSA approach because it did not require the significant training that
might be necessary before using an alternate approach like six sigma. PDSA provided a good
option because it was basic enough for the professional and clinical staff members to grasp
quickly, and the process would not be overwhelming on top of the clinical demands that they
faced. In addition, complex tools were not deemed as essential to the process of achieving this
transformation as developing a problem-solving structure that would also foster a parallel
cultural transformation. The Ninety to Nothing Task Force was created, and it included
representatives of all departments involved in caring for patients during an episode of care in
the emergency department.
The Task Force was chaired by the chief nursing officer and included:
• the emergency department medical director;
• the emergency department nurse manager;
• director of the laboratory;
• staff member from the X-ray department;
• director of the pharmacy;
• director of information technology;
• director of medical records;
• staff member from respiratory therapy;
• staff nurses from all three shifts; and
• nursing department secretary, who was responsible for keeping and circulating
minutes of every Task Force meeting.
Two things were required of the Task Force: to be able to work together to identify
bottlenecks and resolve them together at each meeting, and to learn to view one another as
internal customers.
It was essential to gain buy-in from all members of the Task Force, including department
directors, department representatives, and line staff. While some of the representatives were
from departments that were historically at odds with one another, task force members were Ninety to
carefully selected. The chief nursing officer invited individuals that were known to be Nothing
collegial, collaborative, and open minded, and who were heavily invested in the success of
the organization. They were also recognized as leaders in their own departments, and were
likely to gain the support of their co-workers for the improvements being made. Invitations
to participate were accompanied by a recognition of the special and unique contributions
that each person could make to the effort, an acknowledgment of the challenge ahead, and 367
participants were rewarded with the opportunity to develop a new process through creative
problem solving in an atmosphere free of judgment. The atmosphere for each meeting was
welcoming and positive, and a meal was always provided for Task Force members at the
start of the session. Ground rules were set for respectful and professional communication,
with an atmosphere where all ideas were welcome. The friendly environment, willingness to
take suggestions from all team members, and the growing willingness to compromise
kept the meetings pleasant and engaging, and ultimately, the recognition for achieving
progressive and sustained improvements kept task force members invested. Their
enthusiasm and commitment bled into their respective work areas, another unanticipated
but welcome benefit.

The PDSA cycle

Deming published the PDSA Cycle in 1982 after being introduced to it by Shewhart, his
mentor (Best and Neuhauser, 2006), and it is the approach most often employed in the
healthcare arena when rapid improvement is desired. In this process, problems are identified
in the Plan step, and a strategy to address the problem is identified. Success metrics are also
identified, and the plan is enacted during the Do step. Outcomes, areas for improvement, and
problem resolution are assessed in the Study phase. In the Act phase, feedback plays a
crucial role, and the learning that took place in the cycle is implemented and the process is
repeated until the goal is achieved.

Methodology: the Ninety to Nothing Task Force process

The Task Force met every two weeks initially, and as improvements were made and
sustained, moved to a monthly meeting format. The meeting was held in a room adjacent
to the emergency department, and the atmosphere was focused and cooperative. Minutes
were maintained and distributed to all members after each meeting and the activities of
the Task Force were reported ongoingly by the chief nursing officer to members of the
administrative team.
At the first meeting, the Task Force hung blank sheets of paper on the walls around the
room, and the Task Force brainstormed and every impediment to the reduction of
turnaround time was listed from the perspective of the department affected by it. Ground
rules established the etiquette for group interaction, and blame free language was required.
Once an objective list of impediments was created, the Task Force members reviewed them
one by one and prioritized the order in which they would be addressed. Urgent issues and
those that could be easily addressed were the first to be selected. For the work of the Task
Force, two important rules were identified. First since the turnaround time per month was
an average of the time that every patient spent in the emergency department from arrival to
discharge, it was clear that three separate turnaround targets would have to be established.
For non-urgent patients, like those coming in for the flu or a tetanus shot, a turnaround time
goal of 60 minutes was established. For those that were more seriously ill (urgent but not
emergent), a turnaround time goal of 90 minutes was created, and finally, for serious
emergencies, like a car accident or heart attack, the Task Force set no turnaround time limit.
The time from door to door for all patients seen in the emergency department each month
would be added together and averaged to calculate the new average turnaround time for the
IJHCQA month and to track progress. While the data were potentially skewed by a complicated case,
31,4 with almost 2,000 visits per month the average was deemed sufficient for monitoring the
process because the large sample size would mitigate the impact of a few outliers.
In addition, the Task Force committed to calling every patient that left without being seen
or left against medical advice to solicit information about the reasons the patient left
without treatment.
368 The PDSA Cycle was sequentially applied to each impediment identified. At each
meeting solutions were identified and they were implemented immediately after each
meeting. Results of changes made were evaluated at the following Task Force meeting
and the strategy was either revised if further improvement was necessary, or was adopted
and implemented permanently. Turnaround time was measured continuously and was
reported at each meeting, so that the impact of changes implemented between meetings
could be assessed. In addition, each meeting included a round robin during which each
member could report on the impact of the changes made or could identify new issues to
work on.
Since the quality improvement process was supported by management and owned by
the Task Force, an extensive list of successful strategies was sequentially implemented.
The following process improvements were developed, tested, evaluated, and implemented
by the Ninety to Nothing Task Force:
(1) A charge nurse was designated each shift to facilitate patient flow and to speak to
those in the waiting room at least once every 30 minutes.
(2) Treatment rooms specific to different types of presenting illnesses were created and
stocked appropriately. A triage nurse was assigned to do an initial assessment on
each patient on arrival so that the patient could be routed to a room where the
necessary supplies and equipment were waiting.
(3) Bedside registration on rolling computers was implemented in the emergency
department.
(4) The Task Force determined that asking patients about source of payment/insurance
coverage on arrival was highly offensive and stressful for patients and families in
crisis. The Task Force established a policy the restricted conversations about
payment for services to the last stop prior to discharge. This strategy was very
effective in improving patient satisfaction.
(5) The Task Force identified that delays were being introduced by the nurses’ need to
wait for a physician’s order before carrying out the diagnostic tests that they
knew would be required. This delay could be significant since only one
physician was scheduled in the emergency department each shift. The emergency
department nurse manager, staff nurses and emergency department medical
director established “standing” order sets by presenting symptom that were
signed by the emergency department medical director. These order sets allowed
the nurses to initiate diagnostic tests and facilitated care delivery because the test
results could be obtained quickly and were available when the physician went in to
assess the patient.
(6) Whenever possible, the physician on duty and the triage nurse assessed the
patient together. This prevented the patient from having to repeat responses, and
expedited treatment.
(7) Room status flags and a large whiteboard were installed so that staff could visually
track statuses for all patients by room number (not name, maintaining patient
confidentiality) always, and delays could be avoided.
 (8) Emergency department treatment rooms were renumbered to improve room Ninety to
assignment and patient tracking. Nothing
(9) Historically high volume times were identified, and a physician’s assistant or nurse
practitioner was put on call so that they were available to address less complex
patients during high volume times and expedite patient care.
(10) Staff that logged patients on arrival sat in a vestibule outside of the emergency
department and had difficulty communicating with the triage nurse and charge
369
nurse who were working within the emergency department. The nurse manager
purchased walkie talkies and this problem was eliminated.
(11) Delays had previously resulted from the need to wait for staff in the
cardiopulmonary department to come to the emergency department with an EKG
machine to take EKG’s. To eliminate this impediment, the nurse manager purchased
an EKG machine that was dedicated to the emergency department and its patients.
(12) The nurses found it time consuming to write discharge instructions and to then
review them with patients. They also reported that the need to write the instructions
down interrupted their interaction with the patient, and was a dissatisfier. The nurse
manager purchased Micromedex, an electronic system that printed standardized
discharge instructions by diagnosis. The nurses then spent quality time with
patients reviewing the instructions with the patient, which the patient would take
home, and the interaction encouraged the patient to ask questions.
(13) The Task Force identified a delay in treatment that resulted when patients were
admitted to the hospital in the evening and care was not assumed by the attending
physician until he or she made rounds the next day. These delays were causing
areas of non-compliance with core measures, or mandated standards of care by
diagnosis that were often time sensitive. To address this problem, the emergency
department medical director created core measure compliant standing order sets
by diagnosis that would provide physician orders to direct the care of the patient
until the attending physician assumed care for the patient the next day.
(14) Since patients who were being admitted to the hospital from the emergency
department were not considered discharged until they left the emergency
department and were picked up by the receiving nurse on the unit to which
they were being admitted, the Task Force realized that their average turnaround
time was being artificially extended by delays introduced when nurses on the
inpatient units did not pick up the patient being admitted in a timely manner.
The chief nursing officer implemented a Phone, Fax, and Fly protocol that required
the nurses on the inpatient units to pick the patient up from the emergency
department within 15 minutes of being given a verbal and faxed report from the
emergency department.
(15) The Task Force mandated an orientation to the Ninety to Nothing project for all
physicians prior to their first scheduled shift in the emergency department, and
required them to commit to continuing all the process improvements that were
implemented by the Task Force. Physicians were informed that they were joining a
customer service culture, not simply working a shift.
(16) An Express Care treatment room was created for the care of non-urgent patients.
(17) The Task Force requested that the IT director place all EKG’s on file at the hospital
on the server, so that when patients were returning to the hospital through the
emergency department and had had an EKG in the past, the patient could benefit
IJHCQA from the ability of the treating physician to compare the new EKG with a prior one
31,4 done on the same patient.
(18) Historically, all the contract physicians had been scheduled for 24 hour shifts.
The Task Force recognized that the quality of the physician’s interaction with the
patients gradually deteriorated over the course of the 24-hour shift due to physician
fatigue. The Task Force mandated that contract physicians were scheduled for
370 shifts lasting no more than 12 hours going forward. This significantly improved
patient/physician interaction.
As the project progressed, several significant changes beyond improvement in emergency
department turnaround time were noted. First, communication and hospitality overall
improved in the emergency department, not only between clinicians and patients but also
between staff in all the departments involved in caring for emergency department patients.
Interdepartmental relations improved and teamwork became more evident. Negative
thinking related to the changes being implemented by the new CEO began to diminish
throughout the hospital as hospital employees watched the emergency department
transformation. Not only was the improved turnaround time an excellent basis for a new
marketing strategy for the emergency department, but the outcome achieved by the Ninety
to Nothing Task Force became a badge of honor for the Task Force members and the
emergency department. The emergency department earned the distinction of the
Department of the Year for its achievement, and the improvements made were sustained.

Results
The Ninety to Nothing Task Force met its turnaround time goal in four months. As noted,
the starting turnaround time was an average of 126.92 minutes in the month before the start
of the PDSA improvement process. One month after the start of the process, the turnaround
time dropped 9.6 percent to an average of 114.77 minutes. In the second month, the average
turnaround time dropped another 9.5 percent, to an average of 103.91 minutes. In the third
month, the average turnaround time dropped an additional 7.3 percent to an average of
96.36 minutes, and by the fourth month of the improvement process, the Ninety to Nothing
Task Force exceeded its turnaround time goals and achieved an average turnaround time of
88.64 minutes, a reduction of 8 percent from the prior month and an overall reduction in
emergency department turnaround time of 30.2 percent.
The run chart below shows how the turnaround time changed over time as the PDSA
improvement process continued and the team refined its process (Figure 1).
This improvement was sustained for 2.5 years, until a change in administration at the
hospital did not support the changes in process necessary to maintain the initiative. Staffing
levels were adjusted, staffing for peak times was reduced, and the reduction in turnaround
time in the emergency department was no longer emphasized in the marketing campaign.

140
Average Turnaround Time
120
126.92
114.77
100
96.36
88.64
80

60

40
Figure 1. 20
Average
turnaround time 0
1 2 3 4
Gradually, average turnaround times began to increase, although the committed team that Ninety to
participated in the project were determined to maintain as much of the improvement as Nothing
possible. In any quality improvement process, a sustained commitment from the leaders of
the organization who value quality service delivery is essential for sustained improvement.

Conclusion
The Ninety to Nothing Task Force recognized several important truths about process 371
improvement that can be generalized to other organizations undertaking a major quality
improvement project. First, anything can be accomplished when restrictions are identified
and out of the box thinking to remove them is encouraged and supported by management.
Next, relationships inside the organization must be improved before relationships with
customers can be improved. Third, competent leaders recognize and facilitate employee
contributions, and take advantage of employee expertise and talent. Fourth, sometimes a
simple process change will make a major impact, as it did when the nurse manager
purchased an EKG machine for less than $2,000.00. Finally, the PDSA process encourages
innovative thinking, facilitates rapid and measurable change, and early achievements keep
the process improvement team engaged and energized. In addition, the structure provided
by the team using a PDSA process allowed the organization to depersonalize the changes
needed to achieve the culture change that fostered their success.
In the end, this process was a testimony to Deming’s belief that the change process could
be simplified, and that success was achievable using the PDSA Cycle. The emergency
department staff wanted to deliver high-quality patient care, and the structure provided by
the PDSA Cycle allowed them to measure the progress that they were making, to achieve
their turnaround time goal, and to sustain the improvements made.

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Further reading
Donaldson, M.S., Corrigan, J.M. and Kohn, L.T. (Eds) (2000), To Err is Human: Building A Safer Health
System, Vol. 6, National Academies Press, Washington, DC.

About the author

Gayle Linda Prybutok is an Assistant Professor of Healthcare Administration in the Department of
Rehabilitation and Health Services at the University of North Texas. Prior to her faculty position,
she had a 30-year career as a nurse and healthcare administrator in a variety of healthcare delivery
settings, and most recently serving as the Chief Nursing Officer of a hospital. Her research interests
include: healthcare quality improvement, health communication, health message design, and health
education via social media. Gayle Linda Prybutok can be contacted at: Gayle.Prybutok@unt.edu

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