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What is Process Improvement?

Nurses are often asked to lead or participate in Process Improvement projects, which are different from other types of projects at the hospital. One key difference is that solutions are not known up front but are developed and tested by the team during the project.

Why is this important?

Often, we see problems we’d like to solve or things we'd like to improve and, with the best of intentions, jump to solutions without fully understanding the root cause of the problem. We can end up dealing with the same problem over and over again.

Rather than jumping to solutions, process improvement provides a structured, stepwise, iterative approach to:

  1. Understand the process underlying the problems we see
  2. Involve the people who actually do the work in diagnosing process "lesions" and brainstorming solutions
  3. Validate our assumptions with data
  4. Try our ideas in the workplace using small tests of change (Plan – Do – Study – Act)

MGH has a Process Improvement department that resides in the Center for Quality and Safety and helps teams across the hospital apply process improvement methods.

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Learning Opportunities

  • Partners Clinical Process Improvement Leadership Program (CPIP)
    Designed to facilitate the development of skills and competencies needed by clinical leaders and front-line health professionals across Partners to actively lead and participate in the clinical process improvement efforts required to meet the challenge of a rapidly-changing healthcare system.
  • Process Improvement Primer
    MGH Leadership Academy – Process Improvement Training overview for managers
  • Greater Boston Manufacturing Partnership
    Dedicated to sustaining a strong and vibrant regional economy by improving the operational profitability and competitiveness of existing and emerging organizations, large and small, through training in lean and continuous improvement principles.
  • Lean Enterprise Institute (LEI)
    Develop hypotheses about lean thinking (derived from Toyota), test them in the real world, then diffuse these ideas through a variety of ways, including books, workbooks, workshops, onsite training sessions, and Lean Summits, to help managers and their organizations make the lean leap.
  • IHI Open School
    An interprofessional educational community that gives students the skills to become change agents in health care improvement.

Process Improvement Department

Mary O. Cramer,
Executive Director Organizational Effectiveness & Chief Experience Officer
Massachusetts General Hospital & MGPO

Process Improvement SharePoint Site


Joint Commission logo

The mission of the Joint Commission is to continuously improve care provided to the public and to inspire health care organizations to provide safe and effective. This mission permeates all aspects of the accreditation process. It is reflected throughout the standards and National Safety Goals, many of which require hospitals to identify their risk points, collect and analyze data, and use performance improvement processes to continuously improve care.

Magnet Recognition

Magnet_logoThe American Nurses Credentialing Center (ANCC) describes quality improvement (QI) as the “systematic, data-guided activities designed to bring about immediate improvement n healthcare delivery in particular settings. (Lynn , et al., 2007, p. 667)"



Click here to access Glossary...

There are numerous terms and acronyms in healthcare that may be unfamiliar. Please click here to visit a Glossary of Terms that may be helpful. And please email any suggested additions.

This month's featured term: Process Improvement
Process Improvement draws upon a known set of concepts and tools and applies them in a structured but flexible approach to solving problems. It is usually taught in the context of projects to enable learning by doing and is actively supported by leaders. Process Improvement engages front-line employees in the problem solving process. The ultimate goal is for each individual to continuously bring forth ideas to improve his/her own work, and for everyone to learn how to conduct and evaluate experiments on work processes.

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Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations.

If you have questions or suggestions related to the EED portal, please contact Jess Beaham at (617) 726-3109 or via email at

updated 2/16/17


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