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Continuous Improvement and Employee Engagement, Part 2: Design, Implementation, and Outcomes of a Daily Management System

Maurer, Marsha, MS, RN; Browall, Pamela, MS, RN; Phelan, Cynthia, MS, RN; Sanchez, Sandra, MSN, RN; Sulmonte, Kimberlyann, MHA, RN, CPHQ; Wandel, Jane, MS, RN; Wang, Allison, BA

JONA: The Journal of Nursing Administration: April 2018 - Volume 48 - Issue 4 - p 209–215
doi: 10.1097/NNA.0000000000000601

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 work flow and to address them on a daily basis. Through a DMS, improvement becomes the work of everyone, every day. The authors of this 2-part series describe their work to develop a DMS. Part 2 describes the implementation and outcomes of the program.

Authors Affiliations: Senior Vice President for Patient Care Services and Chief Nursing Officer (Ms Maurer), Nursing Director (Ms Browall and Ms Sanchez), Associate Chief Nurse (Ms Phelan and Ms Sulmonte), and Program Director (Ms Wandel), Patient Care Services, and Management Engineer (Ms Wang), Office of Improvement and Innovation, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

The authors declare no conflicts of interest.

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

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s web site (

Part 1 of this series1 describes how work on Lean improvement methods at Beth Israel Deaconess Medical Center (BIDMC) in Boston led to the development of a daily management system (DMS) that enables staff to engage in continuous daily improvement. The unit-based, staff-led system uses a 5- to 10-minute daily huddle to identify local barriers to providing quality care, identify root causes, and plan solutions. This article describes the design and implementation of the program in detail as well as outcomes to date. It shows how structured, standardized work can empower and engage frontline staff by giving them the tools they need to succeed.

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Standardized Calendar Management

A steering group was formed to guide the DMS work. At the outset, members realized that if a new approach to improvement was to succeed, leaders would need time to oversee the process. Yet there was a common perception that nurse leaders felt that too much time was spent in meetings. A subgroup was formed to evaluate the meeting burden faced by the leadership team and to create a standardized approach to calendar management.1 When nurse leaders within patient care services (PCS) were asked to list the meetings they attend, approximately 100 different meetings were named. The subgroup created a visual map of responses that categorized each meeting according to purpose and areas of accountability. The visual tool, something staff had come to rely on through previous Lean training, also helped the subgroup recognize patterns such as redundancy. For example, there were 14 meetings related to the same broad organizational goal.

With an eye toward an overarching goal of employee engagement and adhering to the Lean principle of involving those closest to the work in process improvement,2,3 a 10-question e-mail survey was sent to each member of approximately 50 committees that were controlled by PCS. Respondents were asked to complete 1 survey per meeting they attend and to note the purpose of the meeting, whether they thought the meeting was serving the purpose, whether the topic was also covered in other meetings, the time commitment of the meeting, and their recommendations as to whether the meeting should continue. More than 600 responses were received, with many individuals submitting multiple responses because they were serving on multiple committees.

The subgroup did a deeper dive of the PCS-controlled meetings, drawing on the 5S Lean concepts of sort, straighten, shine, standardize, and sustain.4 They applied this strategy to the inventory of meetings: sorting, organizing, and cleaning up meetings and standardizing an approach to calendar management. On the visual display, a “red tag” was placed on each meeting that was identified as having an unclear purpose, was redundant, or was not fulfilling the meeting's objective. For each meeting with a red tag, 1 of 3 actions was selected: discontinue, combine with another meeting, or simplify by shortening the meeting or reducing its frequency, topic areas, and/or membership. Using this process, we reduced the total number of meeting hours per month within PCS by 51%, eliminating 21 meetings entirely and freeing up 154 h/mo across the division.

Using these “found” hours, the steering group created standardized, protected time for improvement work in the form of three 2-hour “no meeting zones” (Figure 1).5 The no meeting blocks were hardwired into everyone's calendars as a reminder that this was protected time. This not only gave unit-level managers the time to oversee the new improvement process but also allowed members of the nursing executive team to visit the units and evaluate how the improvement work was evolving and whether additional supports were needed.

Figure 1

Figure 1

The next phase of calendar work was aimed at sustainment (the last S). A year after the standard calendar was launched, leaders were surveyed again. Results showed that some new meetings had been added, some during the no meeting zones. As our program matures, we are exploring additional ideas to help us ensure ongoing protected time. Importantly, we were able to effectively use the protected time during the time-intensive phase of our DMS program development and rollout.

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Creating a Continuous DMS

The next task was to design the elements of a continuous DMS, one in which “everyone, every day” was involved in identifying and solving problems.1 In an earlier exploratory phase, members of the steering group had seen examples of systems that tracked 1 People (P) metric at a time, focusing on staff issues, and 1 Quality (Q) metric, focusing on some aspect of clinical care.6-8 This resonated with the group, as did the notion of addressing metrics using a brief (5-10 minutes), regularly scheduled team huddle. The steering group set out to design a visual management system and to develop a process for identifying and tracking metrics using a daily huddle.

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Visual Management System

Members of the steering group designed a visual “huddle board” using a “5-feet, 5-second” rule,9 meaning that anyone looking at the board would be able to get key information in 5 seconds from 5 feet away. This not only helps streamline the huddle process but is also helpful when senior nurse leaders attend huddles because they can quickly see the status of the improvement work on that unit.10 Each unit uses a similar, standardized huddle board (Figure 2) that includes tools to identify and track metrics and improvement strategies. There are 4 key parts to each board. When used together, they allow staff to record on a daily basis: whether a goal was met that day; if not, how much it was missed by; the possible root causes of missing the goal; and actions staff can take to address common root causes. (Supplemental Digital Content 1,, huddle board photo). Each board also incorporates a timer that is set for 10 minutes.

Figure 2

Figure 2

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Identifying and Tracking Metrics Using a Daily Huddle

The process of identifying and tracking metrics occurs in a series of steps summarized in Figure 3. It was decided at the outset that staff would identify the metrics they wished to track. This was in line with the goal of engaging frontline clinical staff and acknowledging that they are best positioned to both notice and solve problems.3,11 The huddle leader encourages staff to use SMART criteria in choosing metrics, meaning each metric is specific, measurable, actionable, relevant, and timely,12 and to choose 1 Q and 1 P metric.

Figure 3

Figure 3

The status of the chosen metrics is addressed daily during the DMS huddle, which occurs at predetermined times each day. Units decide on a huddle schedule that works best for them and determine who the huddle leader will be. Staff members are trained to the huddle leader role during the rollout and education process. All members of the team (for example, support staff as well as nurses) are invited to learn how to lead the huddle.

The huddle leader asks each staff member about the status of the metric from their perspective. For example, the staff may be tracking whether intravenous (IV) therapy is being used according to a standard dictating how IV sites, bags, and tubing should be labeled. The goal may be that 100% of IVs will meet the standard. If the goal was met, a block for that day is colored green; if it was not met, the block is colored red. The individual staff responses are recorded on the trending graph that visually answers the question: “In how many instances was the standard not met?” Huddle leaders then help staff articulate reasons why the standard was not met, and this is recorded on the Pareto chart (for example, the IV tubing was not labeled).

If the goal is not being met after consecutive days, the huddle leader helps staff probe the root causes of the most common barriers trending on the Pareto chart. For example, the chart may show that nonlabeled tubing is the most common reason for not meeting the standard, and the discussion may reveal that labels are not easily available when needed. The huddle leader talks the group through a plan/do/check/act (PDCA) approach to plan “countermeasures.” The term “countermeasure” includes the notion of a dynamic response to systems that are constantly in a state of change.11 Once the countermeasure is in place, the daily huddle includes a discussion of whether the countermeasure is working. The conversation continues daily until the team decides 1 of 3 things: the countermeasure is effective and should be made part of the standard work; the countermeasure works but not perfectly, meaning it should be modified and the PDCA cycle resumed; or the countermeasure does not work at all, in which case the group reexamines the root causes, determines a new countermeasure, and resumes the PDCA cycle. This iterative PDCA process allows for consistent follow-up and quick tests of change. It also allows the people who are doing the work to drive necessary changes, increasing staff engagement. When a goal is being consistently met, a new metric is chosen.

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Training and Support

Members of the steering group trained several pilot units over 8 to 10 weeks using two 3-hour learning sessions. A “check and adjust” process was used prior to implementing on additional units, which revealed that staff were not easily retaining information from the learning sessions. This resulted in several adjustments to the training process. The most important and effective change was to add an experienced clinical nurse, one with previous Lean training, to the training team as an implementation specialist. The implementation specialist’s effects on the program were pronounced. She was able to provide meaningful support, mentorship, and education to staff learning about DMS.

The steering group wanted to build on the success of the implementation specialist role by identifying clinical staff who could be moved into a rotating DMS fellowship. This has become a standard part of the program. The fellows are temporarily pulled from their unit’s staffing patterns. They spend the 1st several weeks of a 6-month fellowship shadowing the implementation specialist and learning about DMS and effective coaching strategies. They are then assigned to work with designated units as DMS coaches and mentors. At the end of 6 months, the fellows return to their units where they become embedded experts in DMS.

Having the implementation specialist and the rotating DMS fellows enabled us to implement a more robust training and support program that we believe has been a key piece of our success.5 The overall curriculum was expanded, with the implementation specialist and DMS fellows providing on-unit support for units ramping up to full implementation of the system. Using embedded staff in this way has enabled us to reap the benefits of what our chief nursing officer (CNO) has called a “small army of experts” who are engaging their peers in a vibrant, evolving system of continuous quality improvement.

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The DMS has been implemented to date on 33 units at BIDMC. The incremental rollout, including the developmental phase on pilot units and ongoing adjustments to our systems and training, spanned just less than 2 years. Across these units, more than 480 improvement metrics have been addressed. Improvements were realized not only in clinical metrics but also in staff empowerment and engagement.

Information on outcomes is based in part on a staff survey that was conducted 18 months after the pilot implementation. The survey asked staff whether DMS was effective in helping them identify and solve problems. At the time of the survey, the stepwise training and rollout of DMS was continuing and some units had more experience or training than others. The steering group wanted to see if survey results differed depending on how well established DMS was on a respondent's unit. To stratify units with regard to their DMS ‘competence,’ the implementation specialist observed DMS activities on each unit, using an assessment tool to record observations. It tracked information such as how frequently metrics were being tracked, whether huddle leaders required prompting to run the huddle, and whether staff were openly participating in huddles. Based on these assessments, units were categorized into 1 of 3 competency groups: advanced, intermediate, and developing. Survey outcomes were analyzed with these competencies in mind.

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DMS Survey Results

When staff were asked whether daily metrics helped them remove barriers in providing patient care, 41% either agreed (35%) or strongly agreed (6%), with 27% responding “neutral” to the item. More positive responses on this item came from those who worked on a unit categorized as “advanced” in its implementation of DMS. Conversely, those who responded disagree (20%) or strongly disagree (12%) were more likely to be working on a unit characterized as “developing” their DMS implementation. We found these results encouraging, suggesting that, if DMS was effectively in place, staff saw it as beneficial in their work to provide needed improvements in care.

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Enhanced Employee Engagement

In the DMS survey of staff, there was a favorable response to questions asking if the DMS system allowed staff to be involved in the decision-making process and helped them communicate about problems on the unit. Less than 25% of the respondents disagreed on these items, with “agree” being the most common response to both questions (42%-45%). By chance, the medical center's employee engagement survey was administered after the DMS had been launched on most of the units. On the unit-aggregated responses to the engagement survey question, “I am involved in quality improvement activities,” every unit that had been rated as advanced in the implementation of DMS scored above the organizational mean; conversely, all units except one that were rated as “developing” scored below the mean on this item (Figure 4).

Figure 4

Figure 4

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Improvement Metrics

We have a growing inventory of success stories resulting from the PDCA improvement cycles that have been implemented. Staff members have reported improvements in pain management, better communication about patients at risk to fall, improvements in patient handoffs, work flow changes leading to more reliable breaks for staff, enhanced employee safety, improvements in how equipment and supplies are stocked, and much more. In a number of cases, staff on different units have tracked similar issues, arriving at similar, effective countermeasures. These are shared through a 1- to 2-page newsletter that the implementation specialist sends monthly to the staff so that improvement ideas can be spread throughout the system.

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Discussion and Next Steps

The DMS has been one important step in a broader journey to create systems that improve care and reduce errors. We chose this approach because we believed it represented a practical, achievable way to begin to shift our focus from project-based improvements that are difficult to sustain to a vibrant system of continuous daily improvement. Although truly transformative systemwide changes can take decades to achieve, nurse leaders in organizations at any stage can take steps to begin the process, understanding that even these small steps require forethought and planning. Our timeline from project kickoff to implementation across 33 units spanned 2 years. For this type of work to succeed, a long-term, well-supported commitment to change is essential.5,10,13 To quote a mantra that has guided our process, “Lean is a journey, not a destination.”3 (p74)

Lean ideology teaches that employing Lean methods such as a DMS improves employee engagement.2,3,5,14 Our experience has borne this out. Units at BIDMC that were further along in implementing DMS were more likely to score above our organizational mean when asked about engagement in quality improvement activities. Additional, unexpected benefits have also been realized. Early on, the DMS coaches were capitalizing on the ability of the standardized huddle to expose and unpack issues around teamwork that may have been smoldering under the surface. For example, one unit chose to address the P metric of whether staff members were getting out of work on time. Huddle discussions quickly unearthed variation in work practices and in the expectations staff had of each other. For some, leaving on time was more important than it was for others, and staff tended to structure their work according to their own preferences; many were unaware of how their choices regarding work pace were affecting the team. The huddle provided a safe space to uncover the issue and come to a shared understanding of the best way forward. We are excited about the potential of systems like DMS to improve teamwork and perhaps reduce instances of lateral violence in nursing.15

We have early evidence that improvements at the unit level are beginning to organically align with our operational goals, and we believe that, with a critical mass of these successes, improvements in our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and other publically reported measures will develop. Importantly, the steering group decided from the outset that rather than focusing directly on HCAHPS, it was important to leverage the knowledge and expertise of frontline staff in calling out and solving problems important to them. By creating what others have called an “insatiable appetite for improvement,”3 we are confident that broad improvements in patient care and patient and employee satisfaction will result. The value of one element of this approach, having key metrics pertaining to the current condition visible to staff on a daily basis, cannot be overstated.10

Barnas5 has noted that sustaining Lean improvement, and achieving continuous daily improvement, requires attention to an organization’s management system. Embedding Lean methods and expertise changes the way frontline staff members do their work; this requires a change in management systems as well. The steering group is currently working on the next phase of this continuous improvement initiative, creating and implementing a system for leader standard work (LSW) involving standardized reporting and tiered communication.

This work was greatly enhanced by the participation of management engineers from the organization’s Office of Improvement and Innovation. They provided overall project support, with expertise in Lean methods. Partnering with these colleagues improved the “Lean literacy” of both leaders and staff and has been a critical component of our success.

Embedding a standard improvement process for both frontline staff and hospital leaders is part of an emerging trend in healthcare that recognizes the value and the power of standard work. Healthcare in the United States has long been characterized by medical research that adheres to rigorous scientific standards, but a practice system that harkens to its early days in the apprenticeship model, where every clinician is autonomous and standardization, is decried as “cookie-cutter medicine.”9,16-18 Lean methods such as DMS are among the many tools that are teaching us the value of standardization in practice. They are showing that standardizing critical elements can not only improve care in myriad ways but also create a more stable, efficient environment in which appropriate and safe customization is easier to achieve.3,10,16,17 We believe this trend will lead to safer, more efficient, and more patient-centered care.

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