Beyond improving processes, to have a long-term impact, healthcare providers need to engage all stakeholders in creating a culture that continuously focuses on improving patient care.11 To increase the likelihood of sustaining these improvements, we developed our ADM principles. Rooted in Lean methods, ADM reengineers these tools for application in a hospital setting. Specifically, a team composed of nursing leadership and ED physicians worked to create standard process descriptions for essential management functions. The 1st of these management functions are Gemba rounds. Gemba rounds are daily visits to patient care units by nursing and physician leaders to support new processes and actively engage in process improvements. During these rounds, leaders observe how teams are progressing with improvement work, assess whether results are being sustained, and build staff capacity around problem solving. To be successful, leadership must build a relationship with clinical staff and demonstrate an emphasis on performance improvement rather than blame or criticism.