Elevating Care Through Nurse-Led Continuous Improvement (CI) Initiatives

From emerging technologies to shifting patient demographics and increased demand for quality and safety, hospitals are under constant pressure to adapt, innovate and improve. At the heart of these efforts lies a powerful but sometimes under-recognized force: nurses.

Although hospital leaders are frequently at the forefront of strategic initiatives, it is the front-line caregivers who often identify gaps, initiate practical changes and ensure sustainability. Whether it’s reducing patient falls, improving medication administration or enhancing communication among care teams, hospitals that foster a culture of continuous improvement (CI) have been shown to demonstrate better patient outcomes, higher staff satisfaction and lower operational costs.

A culture of learning and progress

Nurses are uniquely positioned to drive CI thanks to the clinical insights they derive from their close, consistent contact with patients, explains Kerry A. Major, DNP, RN, NE-BC, Vice President, Chief Nursing Officer, Florida Region and Cleveland Clinic Weston Hospital. “Nurses often notice inefficiencies or safety risks before anyone else, and — when empowered to voice their concerns — they can guide process changes that improve relationships, reduce errors and increase patient and staff safety and satisfaction,” she says.

In 2024, after noticing a concerning trend in discharge delays, Weston’s nursing team implemented countermeasures that quickly offset the problem. By prioritizing early discharge planning, leveraging medical records to streamline the documentation process and improving communication with post-acute providers, the hospital successfully reduced its discharge delays by 32%.

“The results reflect positive momentum and the sustained impact of CI interventions,” Major says. “When we commit to evaluating current practices and seeking ways to do better, even small changes can lead to major improvements over time.”

“As the largest segment of the healthcare workforce, nurses can help hospitals unlock tremendous potential,” says Julie Fetto, MBA, BSN, RN, NE-BC, Vice President, Chief Nursing Officer, Cleveland Clinic Medina Hospital. A CI project spearheaded by Fetto’s team is a case in point.

Concerned about the spread of highly contagious bacteria, nurses at Medina Hospital set out to reduce the incidence of hospital-acquired Clostridioides difficile (C. diff) infections, a potentially life-threatening problem that can prolong inpatient stays and increase the cost of treatment.

After studying their infection-prevention protocols, the Medina nursing team retooled their processes to close any potential gaps that could increase the risk of contamination. The revised approach requires nurses to use standard personal protective equipment (gown and gloves) when providing stool incontinence care, regardless of the patient’s isolation status. In addition, they were expected to accurately document and describe the patient’s stool patterns in the medical record, preferably soon after admission.

“To encourage adherence to the revised processes, the hospital’s Nursing Quality team performs weekly audits to confirm consistent documentation,” Fetto says. In addition, when inpatient nurses noted a new stool pattern, they were required to complete a documentation form and discuss their findings with the patient’s providers.

“An accurate account of stool patterns from the time a patient is admitted, combined with an accurate assessment of their preadmission bowel patterns, makes it easy for clinicians in the care continuum to recognize notable changes in the patient’s health,” Fetto explains. “The success of our CI C. diff project emphasizes the fact that nurses’ insights are grounded in lived experiences, and their commitment to patient care makes them natural allies in any effort to improve.”

Measuring and celebrating success

Hospitals that succeed in CI often rely on shared governance, a model that provides nurses with a formal voice in decision-making, explains Craig Tobias, MSN, MBA, RN, Vice President, Chief Nursing Officer, Cleveland Clinic Avon Hospital.

Supported by Cleveland Clinic’s Continuous Improvement Department, the model allows nurses to address issues like workflow inefficiencies, patient education gaps and staff training needs.

“The key is that nurses are not only encouraged to identify problems but are also supported in developing and testing solutions,” he says.

A recent project launched at Avon Hospital further emphasizes the central role that data plays in CI. After recognizing several stumbling blocks that were hindering the throughput of their orthopaedic surgery patients, Avon’s nursing team initiated a new protocol to increase the rate of same-day discharges.

Their efforts began by standardizing how case requests were made, procedures were scheduled and patients were prioritized. In addition, case managers began calling patients the week of their procedure to confirm expectations and stress the importance of returning home quickly to recover in familiar surroundings.

“These conversations were designed to reduce miscommunication about acute rehabilitation insurance coverage and increase patient satisfaction,” says Sarah Barak, BSN, RN, Nurse Manager, Post-Anesthesia Care Unit at Avon.

Within a year of instituting the new procedures, the hospital increased the rate of same-day discharges following hip and knee surgeries from 7% to 32% — an improvement that reduced costs and preserved valuable inpatient beds, Barak explains.

“Seeing the improved data is a reminder that what we do matters,” she says. “When patients can recover in a familiar space — their own homes — they have better outcomes and are at less risk for hospital-acquired infections. In addition, when a patient can go home within hours of their procedure, it also frees a hospital bed for someone else in need.”

Clinical Nurse Specialist Michelle Thomas, MSN, APRN, ACCNS-AG, describes leading another CI project at Avon Hospital designed to improve the accuracy of documenting patients’ fluid I&O, a process that ensures patients are maintaining proper hydration and electrolyte levels.

By collaborating with the hospital’s Food Services team, nurses improved their ability to capture patients’ oral intake before meal trays were collected. Additional countermeasures involved creating clinical education materials and implementing reminders for both patients and nurses.

“We get a clearer picture of our patients’ health by carefully recording every bit of fluid they consume or excrete, which helps the team create an appropriate and accurate treatment plan,” Thomas says. “CI is all about using those details to prevent complications and guide our patients on their path to recovery. Projects like this one are an important reminder that meaningful change often begins with those closest to the patient: nurses.”

Empowering caregivers

Concerned that clinical caregivers could be doing more to stem the national surge in workplace violence, nurses at Cleveland Clinic Medina Hospital recently developed a simple, discreet safety icon to improve caregiver safety and situational awareness. The icon — an orange-and-blue square magnet that can be affixed to a patient’s doorframe — alerts nonclinical caregivers to check in with the patient’s nurse before entering the room.

The door sign serves as a trigger for staff to seek pertinent information regarding the specific risks a patient may pose, explains Donielle Finding, MSN, MBA, RN, CCRN, NEA-BC, Director of Nursing at Medina Hospital.

“Healthcare employees are five times as likely to experience workplace violence as other employees, so it’s critical for hospitals to do everything they can to create a climate of safety,” she says. “Workplace violence not only affects the mental health and well-being of nurses, but it can also trickle down and compromise patient safety and satisfaction.”

Finding says the campuswide use of the orange-and-blue squares, implemented last year, has reinforced the hospital’s commitment to safety and increased the confidence of staff entering patient rooms.

“A seemingly small addition to our safety protocols has given caregivers an awareness of the unique needs of certain high-risk patients and preparedness to seek assistance, if needed,” she explains. “Our success illustrates how CI enables nurses to make data-driven decisions, identify areas for improvement and implement targeted solutions.”

Perhaps most importantly, the initiative has been a simple yet powerful reminder of the need for caregiver safety, Finding says. “Caregiver safety is a critical priority for sustaining a healthy, resilient workforce,” she adds. “By promoting a culture of safety, nurses can advocate for the protections and resources they need to perform their roles effectively.”

Major notes how CI is changing the health system’s approach to work by providing caregivers with a mindset and tools to enhance quality and reduce costs.

“Nurses don’t just follow procedures — we shape them,” she adds. “At the end of the day, everything we do should come back to the patient. If we’re always learning, always improving, then we’re giving our patients the best we have to offer.”