Daily Management System to Improve Performance in a Behavioral Health Primary Care Practice

Special Article � Quality Improvement

J Fam Med. 2015; 2(6): 1044.

Daily Management System to Improve Performance in a Behavioral Health Primary Care Practice

Whitley SD1,2,3*, Estes DS1,2, McKenzie ME4, Salimi K1,2, Barada B¹ and Merlino JP²

¹Behavioral Health Services, New York City Health + Hospitals, Kings County, USA

²Department of Psychiatry, State University of New York Downstate, USA

³Department of Family Medicine, State University of New York Downstate, USA

4Breakthrough Office, New York City Health + Hospitals, Kings County, USA

*Corresponding author: Whitley SD, Director of Integrated Ambulatory Behavioral Health Services, New York City Health and Hospitals Kings County Hospital Center, 451 Clarkson Avenue, Brooklyn, NY, 11203, USA

Received: November 15, 2015; Accepted: December 24, 2015; Published: December 28, 2015


Daily Management System (DMS) is a quality improvement tool based on daily team meetings and visual management with input from physicians, nurses, clerical staff, and management to facilitate a data driven; action oriented, engaged, and empowered team of problem solvers. The team identifies performance metrics, sets goals, uses problem solving skills, implements small changes, and measures impact of those changes. We provide an introduction to DMS and describe our experience in a primary care practice located in the Behavioral Health building of a large urban public hospital. These efforts resulted in an increase in first appointment of the day starting on time from 3% in September 2014 to 58% in September 2015. Our efforts to decrease No Show Rate have resulted in modest success to date (50% to 40%). Our problem solving process has resulted in improved understanding of the issues involved and revealed new potential solutions. Our experience demonstrates the feasibility of implementing DMS in a primary care setting and supports the hypothesis that DMS is a cost effective tool that can be used to identify and improve key performance metrics. These tools and lessons learned can serve as a starting point for any practice looking to implement a similar quality improvement process.

Keywords: Continuous Quality Improvement; Daily Management System


DMS: Daily Management System; PCB: Process Control Board


All practices face common management challenges that contribute to low productivity while reducing the satisfaction of both providers and patients. Our Behavioral Health Primary Care Clinic was established in 2011 with the goal of improving access to primary medical care for patients receiving Behavioral Health Services in a large urban public hospital. Multiple studies have highlighted the health disparities for individuals with mental illness and substance use including reduced life expectancy compared to the general population [1-3]. Premature mortality is most often associated with comorbid medical conditions such as cardiovascular disease. While modifiable risk factors including smoking and obesity are more prevalent in the population seeking Behavioral Health Services, these individuals often fail to access appropriate prevention and treatment. A three-month analysis of referrals of our Behavioral Health patients to the main hospital’s Primary Care Clinic confirmed that 88% of individuals referred were not successfully linked to care.

With this in mind, our Behavioral Health Primary Care Clinic was designed to provide care in a convenient location with providers trained and dedicated to working with this complex population. The clinic now serves approximately 800 individuals ages 24-70 and majority African American and Caribbean. All are receiving Behavioral Health Services at our hospital for a range of psychiatric disorders including psychotic disorders, mood disorders, and substance use disorders. Collocation, however, did not fully solve these problems and further effort was needed to improve financial viability, and patient outcomes.

Our clinic continued to face common challenges. There was dissatisfaction among staff and patients regarding long wait times. A preliminary analysis revealed that the first appointments of the day were starting more than 15 minutes late 97% of the time. When the first appointment of the day starts late, a provider can spend the entire session trying to catch up. No show rates were averaging about 50%. Missed appointments contribute to medical vulnerability, reduced access, increased staff effort for rescheduling appointments, and reduced productivity and revenue [4,5]. Reminder calls can be easily implemented and have been associated with improved attendance in comparison with no reminder and postal-reminders [6,7]. The challenge was to easily monitor the implementation of such an intervention and insure that this intervention is effective in our specific patient population without investment of substantial resources.

Leadership was seeking a mechanism to prioritize improvement efforts and engage front line staff in the quality improvement process. An opportunity was identified to test Lean process improvement, specifically DMS, as a tool to address these challenges. We set out to demonstrate the feasibility of using DMS to clarify and improve key performance metrics.

Materials and Methods

DMS is a focused visual management structure that creates, accommodates, and sustains a culture of continuous improvement [8]. DMS facilitates a data driven; action oriented, engaged and empowered body of problem solvers focused on eliminating waste and improving process. True continuous improvement activity happens every day, at any time, by anyone and everyone. DMS makes performance management visible and transparent through daily monitoring of performance metrics tied to organizational goals. DMS, based in the principals of Lean process improvement, makes it possible to facilitate the elimination of waste and process variation [9,10]. Lean process has been successfully applied to medical settings, including Behavioral Health [11]. DMS hinges on staff empowerment and fosters teamwork among staff at all levels, continuously improving their delivery of patient care. It brings problem solving and process improvement as close as possible to the point of impact by engaging the whole team in identifying and solving barriers to providing the best patient care and by providing managers with tools to coach staff and align work to incremental progress towards organizational goals.

DMS Team Members are front line staff working in the clinical area including doctors, nurse practitioners, nurses, nursing assistants, administrative, and clerical staff. Five process improvement metrics were selected by the team, with input from leadership, to insure alignment with institutional goals. Each metric is “owned” by an assigned team member responsible for the collection and recording of data. Daily briefs are conducted in front of the DMS Board at the beginning of each workday, led by a designated team leader, and lasting no longer than 10 minutes (Figure 1). Metrics are selected that are relevant to improving patient care delivery activities in five main categories: Human Development, Quality and Safety, Timeliness and Delivery, Finances (Costs and Revenue), and Growth and Capacity. Improvements in any of these areas would yield the most gain and/ or eliminate the most waste in the process. Metrics, tailored to the processes of the unit within these categories, are updated daily, and trended over time against specific measurable goals. Each daily huddle focuses on one of the five selected metrics in a weekly rotation. Supervisors attend weekly to observe the process, ensure maintenance of the board, and assist with addressing any barriers. This requires a significant time investment up front, but once the board is running, staff is involved for 10-20 minutes per day. The financial cost for materials to build and install the board is less than five hundred dollars.