How Process Mapping Reduced Our Hospital’s HAIs by 28%

Hospital-acquired infections (HAIs) remain one of the most pressing challenges in healthcare. Despite strict protocols and infection control measures, patients continue to contract preventable infections during their hospital stay. At Kaizen Consulting Solutions, Inc., we believe that true progress starts with understanding the root of the problem. In one recent hospital engagement, we used process mapping to reduce HAIs, and the results were remarkable: a 28% reduction in six months.

In this post, we’ll walk you through how we applied process mapping techniques to identify infection risks, improve workflows, and create a culture of accountability across clinical teams.

What Is Process Mapping and Why Use It?

Process mapping is a visual representation of a workflow that outlines each step in a process from start to finish. When used effectively, process mapping can:

Reveal inefficiencies and redundancies
Highlight gaps in communication and handoffs
Identify steps that increase infection risk

Using process mapping to reduce HAIs enables hospitals to examine how care is actually delivered on the frontlines, beyond what policies and protocols say should happen.

Step 1: Forming a Multidisciplinary Team

To begin our initiative, we formed a multidisciplinary task force, including:

Infection preventionists
Nursing staff
Environmental services
Quality improvement specialists
Frontline clinical leaders

Bringing diverse voices together ensured we had a comprehensive view of workflows that impacted infection control. The goal was not to assign blame, but to gain insight into where breakdowns might be happening.

Step 2: Selecting High-Risk Processes to Map

We chose to focus on several key processes known to influence HAIs:

Central line insertion and maintenance
Foley catheter placement and care
Environmental cleaning during room turnover
Hand hygiene compliance during patient rounds

By focusing on these critical activities, we used process mapping to reduce HAIs by drilling into the specific tasks that posed the highest risk of contamination.

Step 3: Observing and Mapping Workflows

We conducted shadowing sessions, time-motion studies, and staff interviews to document how tasks were actually being performed. These insights were then translated into detailed flowcharts.

What we found was eye-opening:

Hand hygiene steps were frequently skipped during room entry and exit due to time pressure.
Catheter care often lacked proper documentation, with no clear ownership between shifts.
Environmental cleaning protocols were inconsistently followed, particularly on nights and weekends.

By visualizing these patterns, the team could see where infection risk was inadvertently being introduced.

Step 4: Identifying Gaps and Risk Points

With the maps complete, we identified several high-risk gaps:

Breaks in standard operating procedures during patient transitions
Ambiguity in roles related to device maintenance
Missed handoff communication between nursing and environmental services

Using process mapping to reduce HAIs gave us clear, actionable data that we could bring back to leadership and frontline teams.

Step 5: Co-Creating Solutions with Frontline Staff

Solutions weren’t imposed from the top down. Instead, we held improvement workshops with the staff who live these workflows daily. Some of the most effective interventions included:

Installing visual reminders for hand hygiene at every entry point
Creating standardized checklists for central line and catheter care
Assigning cleaning champions to audit and coach environmental services staff
Establishing ownership protocols so every task had a clearly designated responsible person

Because staff were involved in crafting solutions, adoption was high, and accountability improved significantly.

Step 6: Measuring Impact and Sustaining Gains

Within six months of implementation, the hospital saw a:

28% overall reduction in HAIs
35% decrease in catheter-associated urinary tract infections (CAUTIs)
22% improvement in hand hygiene compliance

Monthly audits, real-time feedback loops, and quarterly process mapping reviews helped maintain momentum and ensure continuous improvement.

Lessons Learned

Visual tools drive insight: Seeing the process mapped out in real time allows staff to connect the dots between actions and outcomes.
Staff engagement is essential: The more involved your team is in identifying and solving problems, the more likely changes will stick.
Small changes can yield big results: Many of our gains came from tweaks in workflows and clarifying responsibilities.
Ongoing audits are key: Process mapping isn’t a one-time event; it should be integrated into your regular performance improvement cycle.

Final Thoughts

Using process mapping to reduce HAIs isn’t just a quality improvement tactic—it’s a strategic imperative. By shining a light on everyday workflows, healthcare leaders can empower their teams to deliver safer, more consistent care.

At Kaizen Consulting Solutions, Inc., we specialize in helping healthcare organizations implement sustainable process improvements that drive real outcomes. If you're ready to reduce HAIs, optimize operations, and improve patient safety, contact us today to learn how we can help.