Nemaha County Hospital recognized the need to decrease medical errors and reduce variation in their care delivery processes. Utilizing an internal audit tool they identified variation in multiple processes and decided to reduce this variation and eliminate II unnecessary steps, thus providing care more reliably. Department directors identified processes to be audited. Audit teams do not audit their own departments, allowing for “fresh eyes” to examine each process.
Through the use of these audit teams, they were able to reduce the number of policies and procedures by 35 percent, reducing redundant and unnecessary procedures. When focusing on the specific procedure regarding advanced directives, they were able to achieve a 50 percent increase in patient awareness of the need for advanced directives to guide their care.