Case Study: “Night Shift ‘Quietly’ Rocks!!”

Joanne Bayless, Director, Service Excellence, Olympia Medical Center

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That is what the monthly hospital employee newsletter, “Olympia Times” headline (Figure 1) read in November 2012 after years of struggling to move the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction (CAHPS, 2013) scores at Olympia Medical Center in Los Angeles, California. This 204 bed community hospital was struggling with a number of the HCAHPS survey questions. The HCAHPS survey question, “How often was the area around your room quiet at night?” scored lowest. For the first hospital pay-for-performance (CMS, 2011) period, July 2011 to March 2012, the percent of patients who answered “Always” was lower than the baseline period. Second quarter 2011 “Quiet at Night” scores were at the 22nd percentile.

In January 2012 leadership moved its day shift patient rounding to night shift. Leaders interviewed patients from 7:00 to 8:30 p.m. Televisions were loud, linen cart wheels were noisy, and doors that squeaked when opened were just a few of the issues leadership observed firsthand which were contributing to low scores. Instead of leadership fixing the problems a decision was made to place the solution in the hands of the charge nurses who work at night. The charge nurses were tasked with coming up with an action plan to improve the “Quiet at Night” scores. There were posters hung outside patient rooms (Figure 2), the Yacker Tracker (2013) (Figure 3) was implemented in one area to alert staff to high volume noise levels and others were reminding employees to be quiet. The scores inched up slowly.

During the Avatar International Annual Symposium in Orlando, Florida at the end of May, 2012, the Community Hospital of San Bernardino took away four of the “Most Improved” Awards for HCAHPS composite scores. Michelle Bowman, Six Sigma Master Black Belt, Director of Transformation, was instrumental in that hospital receiving the awards. The plane barely came to a stop in Los Angeles when the Service Excellence Director at Olympia Medical Center was on the phone making an appointment to talk with Michelle to find out how she accomplished this. The common thread in their journey was involving frontline employees.

In July the Olympia Medical Center Service Excellence Director woke to thoughts of HCAHPS struggles and decided to surprise the night shift staff and hold a meeting at night. The charge nurses were notified to send a nurse or certified nurse assistant to the 4 West conference room in 10 minutes. They were shocked. A promise was made to only keep the team members for 30 minutes. Respiratory Therapy, Security, Environmental Services, Lab, Radiology and even the Emergency Department were expected to send representatives as well. There was one stipulation; NO SUPERVISORS WERE ALLOWED! It was time for the frontline, point-of-service employees to be given a chance to solve a problem on their own.

Those who showed up were informed of the purpose of the meeting. The hospital stood to lose healthcare dollars if our patient satisfaction scores did not improve. They reviewed the HCAHPS scores for each individual unit at the hospital. They were asked, “What gets in the way of keeping the areas around the patient rooms quiet at night.” The issues were monitors beeping, loud patient vents, agitated patients screaming, staff entering rooms to empty trash, linen and sharps containers after 9 p.m., and noise made by carts, gurneys and bed wheels in corridors. Some new issues were raised such as, the ER bringing admissions to the floors disturbing other sleeping patients, patients’ being disturbed by nursing staff and noise from Engineering and Security radios (Figure 4). Next they were asked for ideas to solve the issues. One nurse suggested not putting vented patients in the area that leads to the Telemetry floor because the sound carries down the hallway. Someone else asked if Environmental Service workers could empty trash in patient rooms before 9 p.m. Thirty minutes into the meeting they agreed to take what they discussed back to their night shift team for additional suggestions. They were told they could not hand this off to their supervisors. As a team, they set a deadline of one week to return additional ideas to the Service Excellence Director. Within 30 minutes of the meeting ending each team member had a copy of the barriers and ideas they generated. Many team members followed through on their commitment to submit additional suggestions within one week. After one of the nursing directors attempted to submit additional suggestions she was informed the suggestions needed to come from the night shift.

One month later the Service Excellence Director showed up at 4 a.m. unannounced. A new set of frontline employees attended the meeting. They were briefed on why they were there, what their fellow team members accomplished the previous month and they brainstormed one more time about additional barriers and solutions.

In September something started happening to the scores. They were on a steady incline although they had not finished the Six Sigma DMAIC process. For the period January 2011 to September 2012 the trend was statistically significant (Figure 5). No one could believe what had happened. This night shift team had taken all the ideas they generated and implemented them throughout the hospital. When these results were presented at the Governing Board of Directors in December one of the members requested an example of the solutions. Examples included greasing hinges on noisy doors, greasing the wheels on the linen carts and moving noisy patients away from alert patients. The board member added, “Nothing that costs the hospital a lot of money.” She was right. Rather than prioritizing the issues the night shift found and implemented solutions to all the problems independently.

At the next unannounced 4 a.m. visit the Service Excellence Director brought chocolates for everyone to celebrate the significant results. The director was advised that her heels were making too much noise and she needed to tiptoe. The teams whispered through the celebrations on the individual units.

The Team Charter (Figure 6), Pareto charts (Figures 7 & 8) and Individual Moving Range charts (Figures 9, 10 & 11) provided evidence the results were significant. The frequency of patients answering “Never and Sometimes” decreased. The Lower Control Limits (LCL) started to move as well. In the 1st quarter of 2012 the LCL was 1.480, 2nd quarter 1.754 and 3rd quarter 2.072.  In November the 3rd quarter scores ranked Olympia Medical Center in the 86th percentile based on the Avatar International database (2012). For the month of September, when the Olympia Times was printed, the night shift “Quiet at Night” score was ranked at the 95th percentile.

Six Sigma refers to a process that produces only 3.4 defects per mission opportunities. The “Quiet at Night” DPMO or defects per million opportunities went from 452,703 to 344,828. The sigma score improved from 1.62 to 1.9. Most businesses operate at a 3 Sigma the goal is 6 or higher (i Six Sigma, 2013) (Figure 12). As of Monday, February 11, 2012, the control chart is still trending upward for the 4th quarter of 2012. The percent of patients who answered “Always” to the “Quiet at Night” question is at 73 percent and this ranks Olympia Medical Center at the 91st percentile in the Avatar International database and the 90th percentile in the National HCAHPS database (CAHPS, 2011).

The night shift went from giving all the reasons their scores would never improve in February 2012 to blowing the socks off everyone, including Avatar International eight months later (Figure 13). In November a representative from Avatar International called asking what we did. What matrix did we adopt? What methodology was it that we could correlate to the marked improvements? They initially seemed disappointed to hear how the night shift heroes didn’t require any sophisticated analysis. That this amazing night shift team took the information and the ideas they generated and made it happen. They made it look easy.

There are many theories regarding what it will require to thrive in the changing environment healthcare is facing today. Porter-O’Grady and Malloch in their book, Quantum Leadership: Advancing innovation, transforming health care, continuously cite engaging point-of-service workers as one of the most important steps to assure healthcare thrives in uncertain times. The question for leaders today is why are we taking so long to adopt this leadership style? Why do we continue to insist that we as leaders must have all the answers? Why do healthcare leaders continue to hold meetings and exclude frontline employees rationalizing that they cannot spare point-of-service workers from productivity standards in exchange for results like this night shift team? It makes sense that the Industrial Age leaders relied on traditional methods to improve outcomes, it was all that was known. Healthcare is changing and so must leaders to thrive in this new age. Olympia Medical Center made this commitment and it paid off. They are committed to continue empowering frontline employees to solve problems.



Figure 1: Olympia Medical Center Employee Newsletter clip.



Figure 2: Signage March 2012 (Courtesy of 4th floor nursing team, Olympia Medical Center).



Figure 3: Yacker Tracker, a device designed to sound an alert when the noise level exceeds defined limits.



Figure 4: Fishbone diagram of barriers to area around the patient room being quiet at night.



Figure 5: Quiet at Night Avatar scores through September 2012 (Avatar, 2012).



Figure 6: Quiet at Night Team Charter.




Figure 7: Pareto chart prior to frontline employee improvement team.



Figure 8: Pareto chart after the implementation of the frontline employee improvement team.




Figure 9: Individuals-Moving Range charts January – March 2012, displays observations in chronological order (left to right) and plots control limits of 3 standard deviations above and below the mean/median.



Figure 10: Individuals-Moving Range charts April – June 2012, displays observations in chronological order (left to right) and plots control limits of 3 standard deviations above and below the mean/median.


Figure 11: Individuals-Moving Range charts July – September 2012, displays observations in chronological order (left to right) and plots control limits of 3 standard deviations above and below the mean/median.



Figure 12: Sigma calculator.


Figure 13: Quiet at Night results as of February 11, 2013 (Avatar, 2013).



Avatar International (2012). Retrieved February 11, 2013 from

I Six Sigma (2013). Retrieved February 14, 2013 from:

CAHPS, (January 9, 2013). HCAHPS: Patients’ perspectives of care survey. Retrieved February 14, 2013 from:

CMS, (November, 2011). Fact sheet: Hospital value-based purchasing program. Retrieved February 14, 2013 from:

Porter-O’Grady, Tim & Malloch, Kathy (2011). Quantum leadership: Advancing innovation, transforming health care. Sudbury, MA: Jones & Bartlett Learning.

Yacker Tracker, (2013). Retrieved February 11, 2013 from


About the Author

Joanne Bayless, Six Sigma Black Belt, Director, Service Excellence
Olympia Medical Center, Los Angeles, California