DMAIC Articles
10 September 2026

Lean Six Sigma in Nursing: Using Time Studies to Free Up Time for Patient Care

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Start DMAIC with the nursing evidence

A nursing time study needs a defined patient-care objective, such as completing scheduled observations on time. In a 2025 study in the Journal of Evaluation in Clinical Practice, researchers observed 34 nurses, comparing 324 hours in 2019 with 314 hours in 2022. Following Lean implementation, they reported a 23.55% reduction in documentation time and increased direct-care time across the services studied. The report on pubmed.ncbi.nlm.nih.gov describes a single-center, observational before-and-after design, which limits causal conclusions.

For a DMAIC project, the finding gives the team a reason to investigate documentation time. It supplies no transferable savings target. A 23.55% reduction in documentation time cannot be presented as 23.55% of the entire nursing shift recovered. The local baseline must establish how much of the shift documentation occupies and which tasks are open to change.

Define the care capacity the sponsor intends to recover

The project charter should name the care activity that will receive the released time, such as patient education or completion of scheduled observations. A problem statement identifies the ward and workflow under investigation; the improvement target follows baseline measurement. “Increase bedside time” needs a definition that observers can apply consistently before it becomes a project metric.

A Green Belt can lead measurement and analysis, with the nursing manager responsible for workflow decisions. Clinical approval for documentation changes belongs in the charter. The charter should also exclude patient identifiers from observation records and rule out individual nurse rankings.

Time-study coding needs a validated measurement system

In its undated workflow toolkit, AHRQ defines a time-and-motion study as observation of task timing and duration. The guidance on digital.ahrq.gov calls for choosing the level of detail and sampling method before data collection and warns against excessive attention to microscopic task details. Within Measure, the intended workflow decision determines how much detail observers need to record.

The observation sheet needs task start and finish times. Activity codes and interruption reasons provide the context for interpreting those timings. Overlapping work needs an agreed coding rule before observation begins: patient education during another care activity must not cause the same elapsed minute to be counted twice in the primary time budget.

ASQ’s DMAIC guidance places measurement-system validation within Measure, as set out on asq.org. For a nursing study, two observers can independently code a shared observation period. Their disagreements show which definitions need revision. Sampling should cover the shifts within the project’s scope, with staffing and patient workload recorded alongside the timings so the team can assess whether the before-and-after periods are comparable.

Proposed DMAIC measure Operational definition Decision supported
Targeted workflow time Minutes in the selected activity per observed nurse-hour Whether the pilot reduced time spent on the selected activity
Direct-care time Minutes in agreed direct-care categories per observed nurse-hour Whether released time reached patient care
Care completion Scheduled observations completed within the locally approved window, divided by observations due Whether the pilot met the intended care objective
Conceptual measurement plan: measure the workflow time released, then assess its use in direct care against completion of scheduled observations.

Use Pareto analysis without classifying every interruption as waste

A 2025 multisite study in the International Journal of Nursing Studies examined delayed and interrupted vital-sign observations across four English hospitals. Researchers identified competing time-critical activities and patient unavailability. The findings reported on pubmed.ncbi.nlm.nih.gov challenged binary classifications of interruptions as beneficial or detrimental. In Lean Six Sigma analysis, an interruption needs clinical review before it receives a waste category.

The project’s Pareto chart should rank causes that clinical review has identified as addressable. Separate charts for event frequency and accumulated minutes distinguish recurring disruptions from those consuming the most observed time. Frequency alone is insufficient grounds for choosing an improvement priority.

During Analyze, an Ishikawa diagram organizes possible explanations for the leading category. Each branch remains a hypothesis until observation or records support it. Choosing a documentation redesign before establishing the cause risks changing a task that contributes little to the measured delay.

Control the transfer of released time into patient care

Before a pilot, FMEA gives the team a structured way to examine potential omissions and delays in the proposed workflow. For documentation changes, the nursing owner should specify which information must remain available and what would trigger a stop to the pilot. The before-and-after study needs the same observation categories and denominator to support comparison.

ASQ’s Control phase guidance specifies long-term measurement and reaction plans on asq.org. In a nursing control plan, each measure needs an owner and an agreed response to deterioration. The revised workflow and its permitted exceptions belong in the agreed process standardization.

If documentation minutes fall while direct-care minutes remain unchanged, the Control review needs to establish where the released time went. The sponsor has evidence of a shorter task; additional care still needs to be demonstrated. Any return-on-investment assessment should report those findings separately and reserve cash-savings claims for verified expenditure changes.

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