Improvement at the Local Level: Our Experience with a Daily Management System
The Problem
Progress to Date
Patient Care Services (PCS) has been building its improvement capacity and deepening its understanding of lean methodology for over
a decade. Although we have had many successful improvement initiatives, our project based approach has faced two challenges:
 Too many meetings
 Manager & staff schedules not
Goal:
aligned
No Time
Total PCS
 Improvement work additive
Meeting
Everyone solving



No consistent way to identify,
prioritize & solve problems
No way to measure daily
performance
No one way to manage daily
problems
Hours
per month
problems,
Everyday
No Standard
Process
After implementation of the No Meeting Zone/Standard Calendar, we designed and piloted daily metrics/huddles on
9 PCS Units.
Monday
Wednesday
Thursday
Friday
Staff: NM
150 hours
freed up!
Eliminated
10 meetings!
Before
After
% Improvement
300
hours/mo
146.5
hours/mo
50%
Staff: NM
Managers
ACN:NM
Staff: NM
ACN mtg.
ACN:NM
ACN:CNO
ACN:CNO
9 – 11a
9 – 11a
ACN:NM
ACN:CNO
PCS Leaders
Ops
HIM
Research
CVI leadership
Network
Devel.
eMAR
Create protected time for
improvement = Standard Calendar
(2 hours, 3 days/week)
Click to see
animation
Tuesday
1 – 3p
Cardiol. Ops
Grant work
group
Click play button to watch a
video of a Huddle!
No Meeting Zone & Leaders Standard
Work Tiered Communications
After revamping the curriculum, we are on an ambitious track to complete implementation of daily metrics/huddles
on the remaining 27 PCS Units. We have designed a sophisticated method for education on the system, and also
have those who have experience with the system mentoring new leaders.
New High Level Curriculum
Goal
By moving away from a project based system to a system that is more standard and sustainable over time, we are aiming to create
an environment where everyone, everyday can continuously improve
Week 1
Marsha Maurer Kimberly Eng
Alice Lee
Allison Wang
BB Wood
Steering Committee
Standard Calendar Team
Tri-Chairs: Elena Canacari, Cindy Phelan, Kim
Sulmonte
Members: Jenn Barsamian, Mary Jo Brogna,
Jane Foley, Pam Browall, Barbara DiTullio,
Barbara Donovan, Chris Garabedian, Phyllis
West
Ad hoc: Dave Mangan, Michelle Sheppard
Team: Jenn Barsamian, Elena Canacari,
Bobby Carney, Donna Clarke, Barbara DiTuillo,
Barbara Donovan, Steven Ford, Lisa Hird,
Chris Kristeller, Tracey Lee, Cindy Phelan,, John
Ryan, Ross Simon,
Alison Small, Kim Sulmonte, Phyllis West
The Vision
Everyone solving problems,
everyday
Daily Metrics and Huddles Design Team
Click to zoom
What is a Daily Management System?
A structured system that enables daily problem solving through providing
focus, engagement, accountability, and alignment
Daily Management System
Time
Targeted
Proactive
Aligned
to Problem Solving
through:
Problem Solving
through:
Problem Solving
through:
Problem Solving
through:
“Overall we wanted to create a complete system that builds a culture where
the people who do the work, are the people who know the work, and can
make improvements”
-Marsha Maurer, RN, MS, Senior Vice President, Patient Care Services and
Chief Nursing Officer
Culture
Values, Engagement, Behaviors, Commitment
Click to learn more
Week 5
Week 6
Setup DMS
board
Week 7
Week 8
Staff
Education
Part 1:
Huddle
Go-live
Implementation
Week 9
Week 10
Week 11
Week 12
13
Sustainment
Week 14
15 16 17
Week 18
Part 2:
Problem
Solving
Go-live
Self- Self- SelfStudy Study Study
Weekly
Unit
Meeting
Team: Jenn Barsamian, Pam Browall*, Elena Canacari, Mary
Francis Cedorchuk, Sue Dorion, Jane Foley, Chris Garabedian*,
Tracey Lee, Michelle Mercurio, Cindy Phelan, Kristin Russell, John
Ryan, Michelle Sheppard, Connie Shulkin-O’Brien, Allison Small*,
Kim Sulmonte, Phyllis West
Mentors (*): Donna Clark, Susan Holland, Sherri Paquette
Implementation Specialist: Sandra Sanchez
Week 4
Lead Huddles (transition to coaching as you train others to lead)
Team
Project Directors
Training
Week 3
Go-live
Learning
Sessions
Sponsors
Week 2
Gemba
Visits
Daily Metrics &
Daily Metrics &
Huddles Pilot B
Huddles Pilot A NMZ & Std.
Calendar Go-Live
Project
Kickoff
Planning
Oct
2013
Dec
2013
Jan
2014
Design
Pilot Feedback & Revisions
Mar
2014
Apr
2014
Sessio
n1
Sessio
n2
Kickoff
Select
Metrics
Sessio
n3
Education: Education:
Track
Facilitate
Metrics
Huddles
Sessio
n4
Sustai
nment
Sessio
n1
Sustai
nment
Sessio
n1
Education: Education: Education:
Reflection
Facilitate Facilitate
Develop
& SustainProblem
Problem
Counterment
Solving
Solving
measures
Implementation of
Remaining 27 Units
Pilot Feedback & Revisions
Jul
2014
Aug
2014
Jan
Oct
2015
2015
Leaders Std.
Work Go-Live
Lessons Learned




Staff engagement is key! It is important for staff to choose measures they care about
Need champions on unit to provide the commitment to make the system sustainable
Can’t let perfect get in the way of good
Daily problem solving has provided a connection among staff increasing team building and communication
Next Steps
 Continue to implement Daily Metrics and Huddles in remaining 27 units
 Continue to work on implementation of Leaders Standard Work
 Begin to work on goal alignment
For more information, contact:
Marsha Maurer, RN, MS – CNO, SVP Patient Care Services mmaurer1@bidmc.harvard.edu
Allison Wang, Management Engineer– Business Transformation, Health Care Quality aswang@bidmc.harvard.edu
Section – The Problem: Things to be animated






Too many meetings
Manager & staff schedules not
aligned
Improvement work additive
No consistent way to identify,
prioritize & solve problems
No way to measure daily
performance
No one way to manage daily
problems
Time
for
No Time
Improvement
No
Standard
Standard
Process
Process
Goal:
Everyone solving
problems, Everyday
Section – The Team: Things to be animated
Sponsors
Project Directors
Marsha Maurer Kimberly Eng
Alice Lee
Allison Wang
BB Wood
Steering Committee
Co-Chairs: Elena Canacari,
Cindy Phelan, Kim Sulmonte
Members: Jenn Barsamian, Mary Jo
Brogna, Jane Foley, Pam Browall,
Barbara DiTullio, Barbara Donovan,
Chris Garabedian, Phyllis West
Ad hoc: Dave Mangan, Michelle
Sheppard
Standard Calendar Team
Team: Jenn Barsamian, Elena Canacari,
Bobby Carney, Donna Clarke, Barbara DiTuillo,
Barbara Donovan, Steven Ford, Lisa Hird,
Chris Kristeller, Tracey Lee, Cindy Phelan,, John
Ryan, Ross Simon,
Alison Small, Kim Sulmonte, Phyllis West
Daily Metrics and Huddles Team
Team: Jenn Barsamian, Pam Browall*, Elena Canacari,
Mary Francis Cedorchuk, Sue Dorion, Jane Foley, Chris
Garabedian*, Tracey Lee, Michelle Mercurio, Cindy
Phelan, Kristin Russell, John Ryan, Michelle Sheppard,
Connie Shulkin-O’Brien, Allison Small*, Kim Sulmonte,
Phyllis West
Mentors (*): Donna Clark, Susan Holland, Sherri Paquette
Implementation Specialist: Sandra Sanchez
Everyone solving problems,
everyday
Design a method that provides an infrastructure for managers
to:
• Structure the way they currently gather information needed
to start the day
• Create shared situational awareness at all levels
• Barriers are identified and proactively responded to
Design an infrastructure for staff to identify,
measure, and solve problems daily on their unit
Daily Management System
Time
Targeted
Proactive
Aligned
to Problem
Solving through:
Problem Solving
through:
Problem Solving
through:
Problem Solving
through:
Create protected time for managers
(2hrs, 3 days/wk) to be more present on
their unit and work on improvement
with their staff
Culture
Values, Engagement, Behaviors, Commitment
Our next steps are to have these problem
solving systems align more closely to
organizational goals
New Detailed Curriculum
Training
Week 1
Week 2
Week 3
Week 4
Implementation
Week 5
Week 6
Setup DMS
board
Go-live
Week 7
Staff
Education
Content for Self –Study Pre-Work can be found on Portal:
Home > Intranets > Clinical > Nursing > General Nursing Resources
> PCS Daily Management System > Educational Resources > Daily
Metrics and Huddles > Self Study Implementation Prework: Weeks 1-3
Self-Study
Week 11
Week 12 13 Week 14 15 16 17 Week 18
Part 2:
Problem
Solving
Go-live
Part 1:
Huddle
Go-live
Lead Huddles (transition to coaching as you train others to lead)
Session 4
Session 5
Session 6
•Understand new •DMS Overview
problem solving •Review
behaviors expected Implementation
•How to select your syllabus
unit
•How to select
implementation
meaningful
team
measures
•Select your
•Do I have the right
implementation
team selected?
team
•How to setup your
•Watch huddle
DMS
example video
•Part 1 (level 1-3):
Conduct an
effective huddle
oReview metrics
oElicit problems
•Navigate barriers
to large cultural
change
•Trending problems
•Change in
approach (firefighting to
proactive problem
solving
•Part 2 (level 4):
Conduct an
effective huddle
oFind root causes
oDaily problem
solving (PDCA
method)
•Coach staff to
develop new
problem solving
behaviors
•Feedback & reflect
on progress
•Empower staff to
make changes
•Develop effective
counter-measures
•Feedback & reflect
on progress
•Sustain & share
gains
•Designate &
educate new
huddle leaders
•Spread to off-shifts
•Feedback & reflect
on progress
•Alignment of local
problem solving
with departmental
priorities
------------------ ------------------ ------------------ ------------------
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2 hours
2 hours
1.5 hours
1.5 hours
1.5 hours
•Meet with your
mentor & walk
their DMS
•Select your board
location
•Order board
•Unit/Staff
awareness
communication
Nurse Mgr & dyad
partner (CNS/UBE)
4 hours
4 hours
Self-Study
2 hours
Session 1
2 hours
Content for Learning Sessions and Unit Meetings can be found on Portal:
Home > Intranets > Clinical > Nursing > General Nursing Resources > PCS Daily
Management System > Educational Resources > Daily Metrics and
Huddles > Learning Sessions and Unit Meetings
Nurse Mgr, dyad
partner (CNS/UBE)
& Implementation
team
Week 10
Session 3
Learning
Sessions
Weekly
Unit
Meeting
Week 9
Session 2
•MyPath Lean
Training
•What is DMS?
•DMS Unit
Expectations
Self-Study
Week 8
Sustainment
Meeting 1
•DMS Education
•See an active DMS
(mentor’s
unit/video)
•Review
Implementation
syllabus
•Brainstorm
potential metrics
Meeting 2 Meeting 3
•Select Metrics
•Create a plan to
track measures
•Plan staff
education
•Education: Track
Metrics
•Practice measure
tracking
•Refine metrics if
needed
Meeting 4
Meeting 5
Meeting 6
Meeting 7
Meeting 8
•Education:
•Education:
•Education:
•Education:
•Reflection &
Facilitate Huddles Facilitate Problem Facilitate Problem Develop Counter- Sustainment
Solving
Solving
measures
•Review new
problem solving
behaviors expected
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1 hour
1 hour
1 hour
1 hour
1 hour
1 hour
1 hour
1 hour