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Building a Culture of Continuous Improvement and Employee Engagement Using a Daily Management System Part 1: Overview

Maurer, Marsha, MS, RN; Canacari, Elena, BSN, RN, CNOR; Eng, Kimberly, BSE; Foley, Jane, MHA, RN; Phelan, Cynthia, MS, RN; Sulmonte, Kimberlyann, MHA, RN, CPHQ; Wandel, Jane, MS, RN

JONA: The Journal of Nursing Administration: March 2018 - Volume 48 - Issue 3 - p 127–131
doi: 10.1097/NNA.0000000000000593

A daily management system (DMS) can be used to implement continuous quality improvement and advance employee engagement. It can empower staff to identify problems in the care environment that impact quality or workflow and to address them on a daily basis. Through DMS, improvement becomes the work of everyone, every day. The authors of this 2-part series describe their work to develop a DMS. Part 1 describes the background and organizing framework of the program.

Author Affiliations: Senior Vice President for Patient Care Services and Chief Nursing Officer (Ms Maurer), Associate Chief Nurses (Mss Canacari, Foley, Phelan, and Sulmonte), and Program Director (Ms Wandel), Beth Israel Deaconess Medical Center, Boston; and Business Transformation Advisor (Ms Eng), Lynn Community Health Center, Lynn, Massachusetts.

The authors declare no conflicts of interest.

Correspondence: Ms Wandel, Beth Israel Deaconess Medical Center, Rabb 251, 330 Brookline Ave, Boston, MA 02215 (

Nurse leaders are facing daily, escalating pressure to make improvements in the care environment.1 Attention to overall quality, always an underlying goal, has gained an urgency and immediacy with the advent of dozens of reportable measures that affect both the financial bottom line of an organization and its reputation within a community.2 No one feels this more keenly than the frontline nurse leader who must engage staff in a continual array of improvement projects, all while doing the basic work of supervising and developing staff, building schedules, submitting payroll, and dealing with myriad daily challenges ranging from sick calls to patient events to issues with facilities and supplies. Competing priorities can leave leaders feeling frazzled, ineffective, and unfulfilled.

A team at Beth Israel Deaconess Medical Center (BIDMC) set out to break this cycle by establishing a sustainable daily management system (DMS) for improvement work that fit naturally into the structure of a 24/7 care environment using Lean principles that were already familiar to many in the organization. Along the way, it became increasingly clear that providing a standardized structure for continuous, daily improvement not only helped advance objectives related to quality, but also provided an effective way for employees at all levels to become empowered and engaged in the workplace.

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Beth Israel Deaconess Medical Center in Boston is a 704-bed acute care teaching and research affiliate of Harvard Medical School. Implementation of daily management at the organization was part of a broader improvement journey. The medical center had been engaged in focused improvement work using Lean principles and methods for some time. Lean principles aim to maximize value in any organization by evaluating processes involved in the organization’s work, specifying desired values, and ensuring that every step in the work process adds value.3 Key Lean management principles include standardizing work, using visual controls to track improvement, and clearly delineating lines of accountability for improvement.4 A baseline of “Lean literacy” among the BIDMC staff helped prime the system for daily management, which has been characterized as a “mature Lean enterprise.”5 Staff were familiar with tools such as visual management systems, and they had begun to understand how a toolkit of Lean-informed strategies and approaches could be extremely effective in meeting improvement goals in complex healthcare systems.4,6–9 The organization’s initial Lean improvement work tended to be unit based and small in scope. Over time, broader, cross-service improvement projects were added.

Some important successes were achieved in this early work. However, structuring improvement work entirely around defined projects had its limitations. One of the most important was the inevitable “project fatigue” inherent in this approach.10 In addition, using intermittent, large projects as a way to improve systems did not fully operationalize a commitment to continuous improvement that was part of the core daily work of patient care and that engaged the larger workforce rather than just select leaders and staff working within a committee or work team that was separated from the clinical unit.

Engaging clinical staff at the point of care was not only consistent with a Lean improvement approach,11 but it also fit well with the underlying culture of the organization, which has a longstanding tradition involving respect for all. In 1972, one of BIDMC’s founding hospitals was the 1st in the nation to issue a “Patient Bill of Rights.”12 Since that time, respect and dignity involving patients, families, members of the community, and staff have grown as an institutional norm.13 The medical center’s “Human First” campaign focuses on the value of individuals; this extends to employees as well as patients and families. This was the backdrop against which leaders in the Patient Care Services (PCS) Division at BIDMC set out to institute a system of daily, continuous process improvement that engaged frontline staff. The goal was to create a standardized approach to identifying and solving problems.

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First Steps

The leadership team visited a number of organizations that had some type of daily management in place.6,14–17 The DMS systems the team observed demonstrated how a structured, standardized approach to daily improvement can be a powerful tool to engage staff at all levels, at the point of care, in a common pursuit of excellence. The DMS operationalized the idea that, if balanced with the right dose of flexibility, structured work can provide staff with the dedicated space to attend to and solve problems, a notion that has been called “flexible regimentation.”6 A DMS steering group was convened to develop a vision for the design and implementation of a customized continuous improvement system within PCS at BIDMC. Led by the chief nursing officer (CNO), the group included leaders and staff from PCS and management engineers from the organization’s Office of Improvement and Innovation. Its charge was to “create an environment where everyone, every day can continuously improve.”

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Creating Time for Improvement

Early in the process, the steering group addressed a challenge that has been noted by others attempting Lean improvement—creating space for leaders to attend to and manage a continuous improvement process.8 The entire leadership team, from frontline managers to the CNO, would need to be engaged in the process of implementing a system in which staff doing the work are able to identify problems and are empowered to solve them.18 Yet the leadership team reported being overwhelmed with meetings; in particular, unit-based leaders were being continuously pulled away from their units to attend meetings, some of which were in place as part of the project-based improvement approach the team was trying to replace. To ensure success, it would be important for frontline leaders to be on their units to help oversee and manage the DMS process because identifying problems at the point of care or service was central to the program’s goals. In addition, it was also important to make sure senior leaders were available to frontline staff for consultation and support.

The 1st several months of the journey were spent understanding and evaluating where leaders were spending their time. A subgroup was formed to address this issue. They applied Lean principles to the analysis of the meeting burden of the PCS leadership team, 1st obtaining an inventory of current meetings, then creating visual tools that helped them categorize meetings and quantify the meeting burden being faced by the leaders. The group set out to eliminate meetings that were no longer serving their original purpose, combine meetings that had related goals or involved the same individuals, and streamline the timing for what remained. Through this process, described in detail in part 2 of this series,19 we achieved a 51% reduction in the number of hours per month that members of our leadership team were spending in PCS-based meetings. To ensure that the new free time would be sustained, a department-wide standard calendar was established that included no-meeting zones—2-hour blocks on 3 days during the week that were to be set aside as protected time for improvement work.

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Standardizing a Targeted Problem-Solving Process

With more time available, attention was turned to developing a standard process for continuous improvement, where everyone solves problems every day. A central concept in Lean improvement is that “problems” are an inherent component of any working system and that continuous improvement depends on providing frontline staff with the means to notice and call out problems and the tools to analyze and solve them.7 The overarching goal was to design an infrastructure for staff to identify, measure, and solve problems as part of their daily work. The structure that was developed had 2 key components: daily DMS huddles and daily metrics. It incorporated key components of DMS that have been described, including visual management and daily accountability.5,18

A detailed description of the design and rollout of targeted daily-problem solving, including a robust program of staff training, is described in part 2 of this series.19 In brief, members of the steering group designed a visual management system (a “huddle board”) to be placed in a central location in each work area. Visual management systems, or visual tracking centers, are a critical component of Lean daily management.6 They provide a succinct visual summary of the current progress of a piece of improvement work. At designated times each day (typically once or twice in a 24-hour period), staff huddle at the board for 5 to 10 minutes. The huddle can be led by any member of the team, including the manager or any member of the clinical or support staff. Together, staff members decide on 2 metrics to track during the daily huddle, 1 related to the quality of the care or service being carried out by the team and the 2nd related to the people doing the work.20 To use 2 examples from our experience, one quality metric had staff tracking whether telemetry electrodes were changed daily for all patients; a people metric on one unit concerned whether everyone took a lunch break. Although these may seem like simple measures, they had a deeper underlying meaning for staff. Failure to change telemetry electrodes in a timely way was contributing to increased false alarms and subsequent alarm fatigue. Failure of staff to take a lunch break was straining workflow and collaborative relationships on the unit. The steering group felt that goals that were set by frontline staff would have the most relevance and meaning for them and would ensure a viability and sustainability of the process and adoption by those involved in the work.6,7 By design, we were careful to avoid presenting the DMS as a top-down process in which goals were preset from the start, and we did not initially attempt to align the DMS work with broad organizational goals. The steering group believed that staff-defined goals would, either initially or in time, align with broader organizational goals. Typically, the same metrics are tracked until an agreed-upon level of improvement is seen. The metrics concern things that occur routinely on the unit, and the evaluation of each metric is typically focused on the previous 24 hours, providing a framework for the DMS principle of solving daily problems in real time.

Each day, the DMS huddle is held at a particular, predictable time. A timer is set for 10 minutes to ensure brevity and viability of the process in the midst of a busy workday. The huddle leader asks target questions about the chosen metrics being tracked, using charts on the visual management board as cues. If the metric is not at the goal level, the group discusses actions that can be taken to move the metric in the desired direction. The status of the metric and proposed actions are recorded in the visual management system. A detailed description of this process is provided in part 2.19

Frontline managers make local decisions about their own level of participation in the daily huddle, based on many factors including how comfortable staff are with the process. As DMS becomes established in each work area, the goal is for the daily huddles to be wholly managed by the staff, with managers attending on an ad hoc basis to provide support and coaching as needed and to keep apprised of issues that may need escalation. In a similar way, members of the nursing executive team also schedule time to attend unit-based huddles, aided in part by the prior work on calendar management. These gemba visits by the executive team have had multiple benefits, including conveying commitment to and support of a staff-led process, gaining insight into the work and challenges of frontline staff, identifying frontline leaders who may be in need of additional support, and identifying leaders and direct care staff who are particularly adept at the process, which has helped us deploy ambassadors and coaches as new units have come online. The DMS huddles were implemented on a unit-by-unit basis. A detailed implementation guideline was provided as each unit came online, and the rollout was facilitated by a trainer who provided concentrated onsite support. Additional detail regarding training and implementation is presented in part 2 of this series.19

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While the DMS steering group continues to study and refine the DMS process, a number of key lessons have been learned. Doing a careful analysis of the meeting burden faced by the leadership team and reducing that burden to free up time for continuous daily improvement work was an important 1st step. While we were initially able to significantly reduce the number of meetings leaders were attending, when staff were surveyed about this issue about 2 years into our process, there had been some encroachment into the defined “protected time” due to ongoing pressure to participate in meetings or other initiatives. This is an area that requires ongoing evaluation, as well as additional sustainment strategies. The steering group is working to develop these mechanisms to ensure that leaders continue to have the time they need to oversee improvement work. We agree with others who have noted that even the best improvement methods must have a process of continuous, daily oversight in order to succeed in the long term and that this element is often lacking when improvement work is project based and not embedded in the organization’s core daily work.5,10,18 While our organization previously had many successes after implementing project-based Lean initiatives, we sought out a DMS because we lacked a reliable way to ensure that improvements were sustained. Donnelly18 has noted, “Both the laws of entropy and the nature of human behavior cause deviation from the standard over time, with the result that Lean systems rely heavily on daily management systems.”18 (p549) Our CNO now says, “DMS is how we do our work.” Process improvement is now embedded in the core work of frontline staff and leaders.

Empowering staff to identify quality metrics, establish goals, envision improvements, and track progress communicates the organization’s respect for frontline staff and impacts staff engagement. It operationalizes the key Lean principle of respect for people and the understanding that continuous improvement depends on the full engagement of those doing the work.6,7 While staff in most US hospitals have long had access to data about their work team’s performance on hospital-wide metrics such as patient safety or cost control, the data are almost always retrospective and are rarely visually accessible as a matter of course.21 These constraints make viable, sustainable solutions difficult to achieve. By contrast, the DMS provides the staff doing the work with fresh, real-time information on quality and invites them to envision and carry out, that day, any improvements that may be needed.11

While the steering group was committed to making sure staff felt ownership of this process, including determining what daily metrics to track, part of the vision at the outset was that a mature DMS would eventually align with organizational goals. This has begun to occur. Many of the metrics that staff have addressed in the 1st 2 years have in fact been related to goals set out in the organization’s annual operating plan. As the program has matured, it has provided a mechanism that leaders can leverage when trying to move forward on broader-based, organizationally defined goals.

Lean Daily Management can be an important tool for healthcare systems to adopt as they attempt to move toward becoming high-reliability organizations (HROs). A DMS helps operationalize key components that have been identified as necessary for HROs, including widespread use of process improvement tools and so-called “collective mindfulness,” where everyone in the organization is watching out for problems.10,22

At BIDMC, the DMS has created a growing feeling among the staff that “problems can be solved.” It has given clinical staff and leaders at every level the encouragement to notice and call out issues in need of improvement. Indeed, we agree that standardizing improvement work, far from being stifling, can unleash creativity in staff.6 We believe that most, if not all, staff want to do their best—both as part of doing what is right for patients and as part of actualizing a fulfilling professional career. A standard, reliable process for identifying, tracking, and improving quality metrics provides a platform that supports staff as they engage in creative thinking about how to get better. This becomes a win-win situation, benefiting patients, staff, and organizations.

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