Being the Best

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Process Improvement

Improving the patient experience.

Process Improvement is a creative and dynamic way of changing hospital culture away from a top-down, manager-driven approach toward one in which everyone in the organization has input. The premise is simple: when everyone has a stake in it, process is improved – and better quality and safety follow. More than 100 Process Improvement projects were started at Cape Cod Healthcare in 2009.

CCH Emergency Center


Since the Cape Cod Hospital Emergency Center implemented the Picis ED PulseCheck®, a leading emergency department information system, the department has dropped its waiting room time to 25 minutes or less. Now, 90 percent of patients bypass the waiting room altogether, heading directly to treatment areas. The average time to see a physician in the department is less than 35 minutes, and the hospital was recently ranked #1 for patient satisfaction nationally by Press Gainey Associates, Inc.

FH Radiology Department

The department improved the way it registered patients arriving for MRI or ultrasound services. The
average waiting time for Radiology was about 30 minutes and it created a backup in the department. Radiology patients are now pre-registered before they come to the hospital. When they arrive for their appointment, they simply sign in to Radiology.

Falmouth Hospital and Cape Cod Hospital Maternity Departments

The departments focused on nursing, dietary, housekeeping, physician participation, marketing and community outreach as ways to improve patient satisfaction. Whiteboards were put up in patient rooms to post daily goals for mother and baby, hourly comfort rounds were started and discharge surveys were conducted.

Focus on the Future

CCHC’s goals this year include process improvement initiatives in areas such as fall prevention, ED performance, throughput, patient access and patient satisfaction.

One major initiative is a reduction in falls, especially falls with injury. CCHC has had good success with this at both hospitals and with the VNA and the JML Care Center as well.  Specific actions have been used to reduce falls and evaluate any patient who has fallen, to assess injury and provide for a quick review of how the fall occurred.