Applying the Four Disciplines of Execution to Promote Culture Change in the NICU

Written By: Elizabeth Jeanson and Bette K. Schumacher


Feeding culture in the neonatal intensive care unit is created by habitual nursing practice patterns, parent availability, and effectiveness of feeding routines. Length of stay in a neonatal intensive care unit (NICU) is affected by infant feeding efficiency. Premature infants acquire oral motor skills and stamina for feeding over time. Failure to understand the complexity of feeding development can result in delayed discharge. In this large regional level 4 NICU, feeding practice had not updated to current evidence-based practice. To modernize feeding practices and improve outcomes, the NICU underwent a culture change project using a unique change model. Unproven in the health care environment, the Four Disciplines of Execution (4DX), a change model developed for business by McChesney and Huling, was selected to facilitate this feeding culture adaptation. The project goal was to reduce cost of care by 5% in 12 months’ time. Lead and lag measures, including education completion, breastfeeding rates, cost of supplies, and length of stay, were used to demonstrate change over time. A commercially available feeding education program, Infant Driven Feeding (IDF™), was selected as the tool for both education and implementation between 2018 and 2019. All premature infants admitted to the NICU were enrolled in the IDF™ program. Following this project, the NICU reduced cost of feeding supplies by $78,000 and length of stay by about 14 days. A full 100% of staff completed education, and breastfeeding experiences increased by 92%. The 4DX proved a highly effective change model for the ingrained culture surrounding feeding at this NICU. This application of the 4DX highlights the importance of using an effective change model to produce robust culture change. Hospitals seeking to improve, update, or change a deeply entrenched culture may find the 4DX an effective strategy.

Jeanson E, Schumacher BK. Applying the four disciplines of execution to promote culture change in the NICU. Pediatric Nursing. 2021;47(5):240-243.