Nursing delegation – Achiever Papers

J Nurs Care Qual
Vol. 33, No. 2, pp.

187

–193
Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

Improving Patient Care
Outcomes Through Better
Delegation-Communication
Between Nurses and Assistive
Personnel

Elissa A. Wagner, DNP, RN

In acute care settings, registered nurses need to delegate effectively to unlicensed assistive person-
nel to provide safe care. This project explored the impact of improved delegation-communication
between nurses and unlicensed assistive personnel on pressure injury rates, falls, patient satisfac-
tion, and delegation practices. Findings revealed a tendency for nurses to delay the decision to
delegate. However, nurses’ ability to explain performance appraisals, facilitate clearer communica-
tion, and seek feedback improved. Patient outcomes revealed decreased falls and improved patient
satisfaction. Key words: assistive personnel, communication, delegation, nursing delegation,
unlicensed assistive personnel

OVER the last 2 decades as health caresystems have implemented processes
to improve communication and team ef-
fectiveness, much attention has been given
to nurse-physician and nurse-patient com-
munication strategies. This is evidenced by
guidelines such as SBAR (situation, back-
ground, assessment, recommendation) to im-
prove communication as well as goal set-
ting for patient-centered care. Professional or-
ganizations such as the Institute for Health
Care Improvement,1 The Joint Commission,2

Author Affiliation: University of Michigan School of
Nursing, Ann Arbor, Michigan.

Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article
on the journal’s Web site (www.jncqjournal.com).

The author declares no conflicts of interest.

Correspondence: Elissa A. Wagner, DNP, RN, Univer-
sity of Michigan School of Nursing, 400 N. Ingalls, Room
2344, Ann Arbor, MI 48109 (elliewa@umich.edu).

Accepted for publication: June 7, 2017

Published ahead of print: August 1, 2017

DOI: 10.1097/NCQ.0000000000000282

and the Agency for Healthcare Research and
Quality3 have widely supported the use of
SBAR to improve effectiveness of communica-
tion. However, less attention has been given
to the delegation effectiveness between regis-
tered nurses (RNs) and unlicensed assistive
personnel (UAP) in acute care settings. To
meet expected outcomes, care delivery mod-
els frequently include UAP in the provision
of direct care and require nurses to be ac-
countable for the care they deliver.4-8 With
the addition of UAP and their written job de-
scriptions, nurses are often unsure about del-
egation aspects and roles and responsibilities
of the UAP.5,6,9 Ultimately, safe care depends
on safe delegation and that requires nurses
to appropriately plan and execute the dele-
gated task. Failure to safely and appropriately
delegate care activities could result in poor pa-
tient outcomes.7 With the emphasis on quality
and safety, connections between delegation,
safety, and outcomes need to be evaluated.

PURPOSE

The purpose of this quality improvement
(QI) project was to determine whether

187

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188 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2018

improving the delegation-communication
practices among nurses and UAP influenced
effective delegation techniques, reduced falls
and pressure injury rates, and improved pa-
tient satisfaction with care on an adult acute
care pulmonary/medical-surgical unit.

LITERATURE REVIEW

Despite the addition of UAP, nurses con-
tinue to struggle with which tasks they can
delegate because of the many different lev-
els of UAP including nursing assistants, tech-
nicians, aides, and patient care assistants.8

Furthermore, contributing factors to dele-
gation difficulties between nurses and UAP
include role uncertainty, lack of trust, ac-
countability, fears of reciprocity, lack of com-
munication, staffing mixes, and attitudes.8,10

Common themes from the literature iden-
tified that poor delegation-communication
resulted in missed care and poor patient out-
comes, leading to longer lengths of stay; in-
creased potential for pressure injuries, falls,
catheter-associated urinary tract infections,
and deep vein thrombosis; and poor glycemic
control.4,8,10

One of the most compelling findings in the
literature was the determination of 9 essential
areas of missed care by nurses and assistive
personnel on medical-surgical units. Kalisch11

identified common missed care as ambulation,
turning, feeding, patient teaching, discharge
planning, emotional support, hygiene, intake
and output documentation, and surveillance.
Many of these are tasks commonly delegated
to UAP and can have a significant impact on
patient outcomes. Also identified were several
reasons for the missed care, which included
poor delegation practices.11

Use of good communication techniques is
the foundation for effective delegation be-
tween nurses and UAP and leads to safe and ef-
fective care. Research related to patient safety
frequently cites communication breakdown
as the number 1 factor leading to errors. For
nurses to enhance safety in what has become
a very complex health delivery system, they
need to use good communication and dele-

gation techniques with the interdisciplinary
team.

METHODS

For this project, a single-group pre-/posttest
design was used to determine the effect of
a delegation-communication learning inter-
vention on both RNs and UAP preparedness
to delegate, knowledge level, use of delega-
tion, mindfulness, supervision issues, and del-
egation decision making. Project outcomes
focused on their ability to effectively use
delegation-communication to reduce falls and
incidence of pressure injuries, and improve
patient satisfaction with care. The project was
considered exempt by the institutional review
board, and all participants were made aware
of the project goals and that their participa-
tion was voluntary.

Sample

The sample was drawn from all RNs (N =
51) and UAP (N = 19) who were currently em-
ployed full- and part-time on a 32-bed adult,
acute care inpatient unit from October 2015
to February 2016. The project unit was within
a large academic hospital in the Midwest re-
gion of the United States with Magnet designa-
tion. Excluded were the clinical nurse special-
ist, clinical supervisor, and manager because
of their participation as clinical champions of
this project. The patient population consisted
of pulmonary disorders and medical-surgical
diagnosis such as pneumonia, congestive
heart failure, cystic fibrosis, lung transplant,
liver disease, cancer, and pancreatic disor-
ders. Care delivery usually included 8 nurses
and 4 UAP with a charge nurse, unit host,
and clerk. Nurses commonly have 4 patients
each, and workload is determined by acuity
and charge nurse report.

Current practice

To establish baseline rates of delegation
practices and identify areas for potential im-
provement, observation of RN/UAP interac-
tion and workflow was conducted by the
principal investigator (PI). An observation

Improving Patient Care Through Better Delegation-Communication 189

guide was developed with common themes
derived from the literature review and del-
egation principles derived from the Ameri-
can Nurses Association (ANA)12 and National
Council of State Boards of Nursing (NCSBN)13

joint statements on delegation (Supplemen-
tal Digital Content, Table 1 available at:
http://links.lww.com/JNCQ/A361). Key ele-
ments included tasks delegated, knowledge
and role expectations, relationship, commu-
nication techniques, omitted care, and use of
ANA rights of delegation.

Baseline observations evaluated 6 RNs and
5 UAP on 2 occasions for 8 hours each, over
a 2-week period. Observations included day
and evening shifts, and during report times
and care delivery to assess the delegation-
communication practices common on the
unit. Initial observations revealed that the
unit had no shared shift report between RNs
and UAP. Each member received report in-
dependently from their corresponding peers.
Patient assignments often required UAP to
work with multiple RNs during a shift as
well. Throughout the observation days, it was
noted that care activities conducted by the
RNs and UAP seemed to occur in isolation
from one another. Information sharing be-
tween nurses and UAP occurred only when
there were changes in patient condition, spe-
cific questions, or movement on/off the unit.
However, the communication focused on spe-
cific needs without providing a reason or rela-
tionship to the patient’s condition. Frequent
social discussions were observed among all
staff in the unit conference room, where doc-
umentation occurs and staffs commonly take
breaks or eat meals.

Data collection

After the baseline observations were com-
pleted, RNs and UAP were asked to participate
in a pretest survey to assess delegation knowl-
edge deficits, delegation competency, role
knowledge, supervision issues, use of mindful
communication techniques, and delegation
decision making. Following the learning inter-
vention, nurses and UAP completed posttest
surveys to evaluate these same areas. Both sur-

veys were tailored to RNs and UAP roles and
responsibilities, and took only 5 to 7 minutes
to complete. Pre- and posttest surveys were
developed and delivered using online survey
software. Survey links were provided to all
nurses and UAP on the unit through institu-
tion employee e-mail as well as on 2 security
enhanced I-pads placed on the unit to increase
participation and access. Pretest surveys were
available to nurses and UAP for a 2-month pe-
riod before the learning intervention. Posttest
surveys were available for 1 month, and par-
ticipation on both was encouraged from the
managers, supervisors, and PI.

Learning intervention

After the pretest surveys were completed,
the PI designed a learning intervention for
improving delegation-communication tech-
niques on the basis of the survey results,
literature review, baseline observations, and
greatest knowledge deficits among the staff.
The delegation-communication learning was
designed using a lecture format and included
information on the purpose of the project,
significance to practice, brief literature re-
view, techniques for mindful communica-
tion, ANA12 principles of delegation, and case
scenarios contrasting substandard and high-
level delegation-communication examples. In-
cluded in the learning intervention were links
to the video “Delegating Effectively” and the
“Delegation Decision Tree,” both developed
by the ANA in conjunction with the NCSBN13

and available to the public on the NCSBN
Web site. To increase participation and ac-
cess to learning, the information was deliv-
ered via several formats that included em-
ployee e-mail with links to the NCSBN video,
unit I-pads, and a flip chart placed in the
unit conference room. Nurses and UAP could
complete the lecture format learning aspect
of the intervention in 10 to 15 minutes
and view the “Delegating Effectively” video
in 20 minutes. Participants could complete
both aspects at once or separately as time
allowed.

After 5 weeks of delegation learning
availability, RNs and UAP were asked to

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190 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2018

participate in the posttest survey to measure
delegation competency, role knowledge,
supervision, use of mindful communication,
and delegation decision making. Data from
the National Database of Nursing Quality
Indicators (NDNQI) on pressure injuries
and falls, as well as Press-Ganey patient
satisfaction levels, were also extracted from
institutional databases during the QI period.

Instruments

Two versions of the pre- and posttest sur-
veys were used for this study, 1 for the RNs
and 1 for the UAP. The survey tools com-
bined 2 instruments from the literature review
and were modified for use in this study: the
Hopkins Learning Needs Assessment and the
Kærnested and Bragadóttir delegation ques-
tionnaire. Aspects from the tool developed
by Hopkins14 to evaluate learning needs and
use of delegation were used with only the RN
sample during the pretest data gathering. Four
scenario questions asked for the best answer
from 3 response choices in a delegation sce-
nario. Means of 1.00 designated poor ability to
delegate, 2.00 designated a tendency to delay
the decision to delegate, and 3.00 designated
a good grasp on delegation. Responses were
evaluated as “has a good grasp, delays delega-
tion decisions, or tends not to delegate” ac-
cording to an established scoring pattern.14

Although reliability has not been established
on the Hopkins tool, it was derived from a lit-
erature review, has face validity, and provided
a guide for tailoring learning interventions to
staff needs.

A second tool developed by Kærnested and
Bragadóttir15 to assess preparedness to del-
egate, supervision, delegation decision mak-
ing, and mindful communication techniques
was modified for use in this project. Ques-
tions from the tool were chosen for their
specificity to the project’s purpose, and ad-
ditional questions were formulated and used
with both RNs and UAP. The tool had an origi-
nal reported Cronbach α reliability coefficient
of 0.63. Personal communication with the au-
thor provided the PI with permission to use
and modify the questions. The questions were

used in the pre- and posttest surveys for both
RNs and UAP.

Both versions of the RN and UAP pretest
surveys included 7 demographic questions; 10
questions on supervision, delegation compe-
tency, and role knowledge; and 12 questions
on preparedness to delegate, mindful commu-
nication techniques, and delegation decision
making. The 10 questions on supervision is-
sues, competency, and role knowledge were
answered on a 3-point Likert scale of 1 = com-
pletely, 2 = partially, and 3 = not at all, with
lower scores being more favorable responses.
The 12 questions on preparedness to dele-
gate, mindful communication techniques, and
delegation decision making were given on
a 5-point Likert scale, with 1 = always to
5 = never. Again, lower scores were more
favorable.

The posttest RN and UAP surveys repeated
the 22 delegation questions for learning mea-
surement. Both RNs and UAP were asked
which delegation learning interventions they
completed (lecture format review, video re-
view, I-pad use, or flipchart review) and to
select the most effective of learning method.

Data analysis

All univariate and multivariate statistics
were computed using the Statistical Package
for Social Sciences (IBM Corp, 2015, Version
23, Armonk, New York). Independent sam-
ple t tests were used to compare the means
for groups with a confidence level of 95%. Fre-
quency distributions, means, and standard de-
viations (SDs) were used to describe the data.
Delegation use by RNs was evaluated from
Hopkins Learning Needs Assessment Tool and
described with means and SDs. Independent
t tests were used to compare both RN and
UAP pre- and posttest survey results on super-
vision issues, role knowledge, delegation de-
cision making, preparedness to delegate, and
mindful communication techniques.

RESULTS

The RN sample (n = 23) included nurses
who ranged in age from 20 to 59 years, 87%

Improving Patient Care Through Better Delegation-Communication 191

were female, and 70% had a BSN-level educa-
tion (Supplemental Digital Content, Table 2
available at: http://links.lww.com/JNCQ/
A362). The UAP sample (n = 14) had an age
range of 18 to 59 years, 71% were female, and
the majority had either a high school diploma
or GED (29%) or a vocational certificate (29%)
(Supplemental Digital Content, Table 3 avail-
able at: http://links.lww.com/JNCQ/A363).

Pretest delegation use

Before implementation of the learning in-
tervention, analysis of RN delegation use with
the scenario questions revealed a tendency to
delay the decision to delegate among the RN
sample according to the established scoring
pattern. Means for the 4 scenario questions
ranged between 2.22 to 2.65. The task of
delegating a bed bath for a long-term, stable
patient had the highest mean (mean = 2.65;
SD = 0.775). Lower means were noted in
scenarios associated with receiving a new
patient from the emergency department
(mean = 2.22; SD = 0.951); making assign-
ments to either UAP or RNs (mean = 2.43;
SD = 0.788); and assigning orthostatic blood
pressures to UAP (mean = 2.48; SD = 0.898).
Overall, the analysis identified that the RNs
tend to delay the decision to delegate and
were more likely to delegate tasks usually
expected in UAP job descriptions.

Preparedness for delegation

Surveys of nurses (n = 23, preinterven-
tion, 45% response rate; n = 14, postinterven-
tion, 27% response rate) on their prepared-
ness to delegate and supervise, role knowl-
edge, decision making, and use of mindful
communication techniques were evaluated
using independent t test to measure effec-
tiveness of the learning intervention. Twenty-
two items were measured, and 18 showed
improvements, 2 remained unchanged, and 2
increased slightly. Four items showed signif-
icant differences after the learning interven-
tion: explaining performance appraisals, fa-
cilitating clearer communication, explaining
tasks, and seeking feedback (P < .05).

UAP (n = 14; preintervention, 73% re-
sponse rate; n = 8; postintervention, 42%

response rate) had 10 items that improved
with the learning intervention. However, only
1 of those showed significance: losing respect
because of delegation (pretest mean = 2.86;
posttest mean = 1.86; P = .039).

Patient outcomes

Patient outcomes assessed during this
project included NDNQI rates of falls and
pressure injury development, and Press-
Ganey patient satisfaction scores for prompt-
ness to call button, pain control, and staff
working together to care for them. Institu-
tional data from NDNQI and Press-Ganey are
reported by specific unit and included dates.
Baseline data were assessed 1 month before
beginning the project and continued during
the 4 months of implementation and 2 months
postcompletion of the project. The unit fall
rate was 2.17 per 1000 patient days during the
month before the project was started. Falls de-
creased to zero and remained at 0 for 4 months
during the project and 2 months after comple-
tion. Hospital-acquired pressure injury rate,
stage II, before the intervention was 3.7%.
The rate fluctuated during the 4 months of
this project, alternating each month from 0 to
4.17. Two months following completion, the
rate remained at 0. Press-Ganey data postin-
tervention revealed little variation over the 4-
month span of the project. One-month postin-
tervention noted an improved promptness to
call buttons (pre = 86.7%, post = 88.7%),
slightly poorer pain control rate (pre =
86.3%, post = 85.5%), and an unchanged rate
of staff working together to care for them (pre
= 90.2%, post = 90.2%).

Learning intervention outcomes

All RNs reported in the postintervention
survey that they completed the learning in-
tervention. Half used the flip chart accessi-
ble on the unit, and the online lecture format
that was sent via e-mail was the second most
used intervention (43%). The UAP learning in-
tervention use was equally divided between
the online lecture format (38%) and not com-
pleting any learning intervention (38%). This
could be reflective of the value of learning in

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192 JOURNAL OF NURSING CARE QUALITY/APRIL–JUNE 2018

professional nurses, the educational level of
participants, or the accountability associated
with delegation for nurses that supports com-
pleting the learning. Results showed that, de-
spite the accessibility of learning, staff chose
to review the content during work hours in
a hard-copy format such as a flip chart or
lecture format attached to their employee
e-mail.

DISCUSSION

The overall results reveal that delegation-
communication difficulties are complex and
occur across a variety of experience levels
of nurses and UAP. Nurses tended to de-
lay the decision to delegate in some circum-
stances except when choices centered on vi-
tal signs or bathing, which is common in job
descriptions of UAP. This is similar to the find-
ings from the literature review that reported
nurses’ difficulty with distinguishing between
delegated tasks and job description responsi-
bilities. It is important for RNs and UAP to un-
derstand the roles of people in their care de-
livery mixes. Doing so fosters a sense of trust,
builds relationships, and allows for clearer
lines of communication among the team. This
was also supported in the UAP postinterven-
tion reduction in feeling a loss of respect
because of delegation. A better understand-
ing of role responsibilities of nurses and UAP
and the purpose of delegation can strengthen
working relationships and diminish feelings
of disrespect. Similarly, delegation difficulties
noted in the observations and preintervention
surveys among the participants paralleled the
literature in communication issues, attitudes,
role uncertainty, lack of trust, and staffing
mixes. There was improvement in these ar-
eas after the learning intervention. Patient
outcomes during the QI period reflected im-
provement in fall rates and patient satisfaction
during and following the intervention. Pres-
sure injury rates fluctuated but remained at
0 for 2 months postlearning. That informa-
tion supports findings from the literature to
suggest that improving delegation practices
and communication between RNs and UAP

can have a positive impact on patient out-
comes and improve patient care. Nurses need
to develop these skills to provide safe and ef-
fective care that includes UAP. Management
staffs also need to support a culture of proper
delegation-communication use among nurses
and UAP to maintain the quality and safety
standards for patients.

Implications for practice

Implications for improving delegation-
communication practice include adding this
to new-hire orientation and requiring yearly
practice competencies for both nurses and
UAP to increase role understanding and sup-
port a culture of delegation on the unit. Once
staff members have foundational knowledge
of delegation principles, exercises can be con-
ducted using the ANA and NCSBN princi-
ples of delegation, the delegation decision
tree, and mindful communication techniques.
Staff would benefit further from participat-
ing in simulated communication and dele-
gation practices to build effective skills, im-
prove mindfulness, and bolster confidence in
delegation-communication.

The initiation of RN and UAP huddles after
reporting times would increase face-to-face
interactions, promoting mindful communica-
tion techniques and opportunities for sharing
of salient information and delegation. Con-
tinued use of independent handoff reporting
maintains care activities done in isolation
from one another, further contributing
to poor communication practices. Finally,
evaluating care delivery models that promote
consistent RN and UAP assignments to
build relationships and trust is also essential
to improving communication techniques,
delegation practices, and patient safety.

Limitations

Although this project provides some evi-
dence supporting the effectiveness of a learn-
ing intervention to improving delegation-
communication between nurses and UAP, it
is limited by its small convenience sample and
short duration on a single unit. Survey ques-
tions were drawn from 2 different tools, one

Improving Patient Care Through Better Delegation-Communication 193

of which had no reported reliability testing,
and selected items were used. A matched pre-
and posttest design would have been ideal for
more accurate measurement of learning. Be-
cause of a high amount of staff turnover dur-
ing the project, independent samples were
used. Another factor that may have attributed
to the reduction in fall rates could be the pres-
ence of nursing students in their clinical rota-
tion during the implementation of the project.
Student presence would allow for increased
surveillance, assessment, and interventions to
reduce falls.

SUMMARY

This QI project revealed the complexi-
ties of nurse and UAP communication tech-
niques as well as barriers to effective delega-
tion. Nurses and UAP need continued support
and education related to proper delegation-
communication for safe and effective manage-
ment of care in acute care settings. Achiev-
ing desired patient outcomes requires a team
approach in current health care and can be
improved with effective communication and
delegation practices.

REFERENCES

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3. Agency for Healthcare Quality and Research. SBAR
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10. Bittner NP, Gravlin G. Critical thinking, delegation,
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J Nurs Care Qual. 2006;21(4):306-313.

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tional Council of State Boards of Nursing (NCSBN).
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ing effectively (video). https://www.ncsbn.org/378.
htm. Published 2002.

14. Hopkins DL. Evaluating the knowledge deficits of reg-
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http://www.ihi.org/Topics/SBARCommunicationTechnique/Pages/default.aspx

https://www.jointcommission.org/standards_information/npsgs.aspx

https://innovations.ahrq.gov/qualitytools/sbar-technique-communication-situational-briefing-model

https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA

http://www.ncsbn.org/378.htm

https://www.ncsbn.org/378.htm

Student Name:

EBP Journal Article in APA format:

.2 points

.4 points

Is this an Evidence Based Article? Name of Journal and Year article was written?	Yes/No Name of Journal Year:		.2 points
State the problem What was the goal of the project in the article? Does this project correlate with your problem? State how? What are you trying to achieve? Does this article support this goal?	Problem: Goal: State how this article correlates with your group problem and goal.
Strengths (Internal) What’s was good about your article?	Why was this project successful? List attributes of the article, i.e. support from administration, councils, colleagues, institutions. Did this implementation take place on a unit or area like yours?	.4 points
Weakness (Internal)- issues	Example: lack of education, lack of staffing, staff readiness, lack of support; size, managerial style.			.4 points
Opportunities (External)	Example: Lack of supplies, educational needs, stakeholders, baseline (your baseline data), what needs to be improved?
Threats – (External)	Staff buy in, support, limitations and barriers, supply cost, cost of implementation, time, money, realistic?

Total Points = 2 points

Student Name: XXXXXXXX

EPB Journal Article in APA format:

Sánchez, M., Suárez, M., Asenjo, M., & Bragulat, E. (2018). Improvement of emergency department patient flow using lean thinking. International Journal For Quality In Health Care: Journal Of The International Society For Quality In Health Care, 30(4), 250–256. https://doi.org/10.1093/intqhc/mzy017

.2 points

.4 points

Is this an Evidence Based Article? Name of Journal and Year article was written?	Yes Name of Journal: International Journal for Quality in Health Care Year: 2018		.2 points
State the problem What was the goal of the project? Does this project correlate with your problem? State how? What are you trying to achieve? Does this article support this goal?	Problem: Delays in the ED compromise quality of care and patient safety while simultaneously increasing mortality and healthcare costs. Internal inefficiencies and poor resource utilization may contribute to delays in care and overcrowding. Goal: The goal of this project was to achieve a target time of 160 minutes (total), per patient in the ED. · 80 minutes of “added value” (i.e. specific amount of time with a nurse and doctor for assessment, treatment, and education) · 60 minutes for lab results · 20 minutes for treatment steps that could not be eliminated using the Lean process The goal of our group project is to propose a plan to decrease wait times and improve flow to care areas. The study outlined in this article directly correlates with our group project in that its aim was to tackle the issue of increased wait times leading to delay of care and negative outcomes, including decreased patient satisfaction and the increased risk for mortality. The goal of our group project is to propose a plan to reduce wait times in order to improve patient outcomes, which is exactly what the article’s researchers set out to do by proposing the use of lean principles to eliminate the unnecessary steps/processes that add to wait times.
Strengths (Internal) What’s was good about your article?	Staff Input: This project was heavily supported by the ED staff and administration. In fact, the ED staff were empowered to make the necessary changes by identifying steps (waste) that slowed flow and hindered the care process. They were also tasked with recognizing processes that could be standardized to improve efficiency in care. Leadership Style: Furthermore, the researchers encouraged a “bottom-up” approach (democratic leadership) to achieve a more enthusiastic acceptance and implementation of the plan. The ED executive team acted as consultants to help support and foster the new process to reduce internal resistance. Cost: The implementation of the entire project was inexpensive because it did not require third party support or additional supplies. Did this implementation take place on a unit or area like yours: Yes, this project was implemented in an ED unit.	.4 points
Weakness (Internal)	Staff Support: According to the researchers, the most difficult problem they faced was staff reluctance to abandon their old practices and proceed with implementing the new process of standardization (which required 3 weeks of constant surveillance). Size: This study was performed in a single ED unit that did not provide services to pediatric or obstetric patients, so it is unknown how well these results might carry over to other specialized ED units. Furthermore, to ensure proper control, the study was limited to a specific unit in the ED, MAT-3, which was the busiest unit in the ED and designated solely for urgent cases.			.4 points
Opportunities (External)	Patient Satisfaction: The results of this study showed that the ED staff was able to reduce wait times, overall care times, and improve patient flow using the lean process to eliminate wasteful steps. However, the researchers could have also measured patient satisfaction to determine if the lean process also improved the correlation between wait times and patient satisfaction. Staff Satisfaction: The authors recognized that additional research should be completed to analyze how the lean process affects staff members in terms of work satisfaction, turnover, and improved use of skills. Baseline Data: The researchers found no significant differences in the revisit rate, mortality rate, or leave without being seen rate (LWBS) after implementing the lean process. Suggestions for additional research meant to address these variables were not provided but should be explored, especially due to their relationship with patient safety.
Threats – (External)	Validity: The researchers acknowledged that one of the greatest limitations of their study was its external validity since the study was performed in only one ED unit. Their methodology might not produce the same results in a more efficiently run ED unit. Time: The researchers also agreed that the cultural change needed to fully adapt to this new standardized process would be an ongoing endeavor that would require additional time after the conclusion of the study. The researchers discounted the first 6 months of data because they anticipated that the staff would be more willing to embrace the new process, resulting in a false-positive outcome. Their aim was to observe how time also impacted the lean process in the ED unit in the following months. Staff Buy In: Finally, the researchers also felt that the cultural/local interpretation of lean principles might differ depending upon location and/or unit. Previous studies concluded that the lean process did not provide clinically relevant results in ED units due to lack of staff buy in resulting from misinterpretation of lean principles. In other words, the staff must understand that the lean process is not a solution but a methodology.

Total Points = 2 points

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