Marleine Elkhouri
Marleine Elkhouri, (L), Nurse Manager, Toronto General Hospital, discusses the unit’s safety board with a nurse. (Photo: UHN)​

New managers at UHN are stepping into the role with the skillset of seasoned leaders, in addition to their extensive clinical experience.

They are former Lean Leads who were seconded from their clinical roles to learn to manage differently. They work alongside UHN's Lean team, a group of coaches hired from private industry for their experience implementing Toyota's world-renowned management system.

Lean Leads are high-performing individuals who typically spend one to two years helping frontline staff and leaders on a unit create positive change using Lean tools and change management concepts. To prepare them for the role they start with applied training in advanced problem solving, a yellow belt in Lean and ongoing coaching.

"This is common practice in industry," says Brenda Kenefick, Director, Lean Process Improvement, UHN. "We are building capacity within the organization and the best way for people to learn the Lean tools and concepts they'll need as managers is to use them to solve problems."

The result of all that preparation is a new breed of managers who enter the role with the skillset and outlook they need to change the organizational culture.

"I think of myself as a leader first in a manager's role," says Sylvie Robinson, Program Manager, Toronto Rehab and former Lean Lead. "As a leader I help my staff work better as a team.

"In my managerial role, I have four main responsibilities: Setting priorities, developing processes to meet goals, continuously improving processes, and developing people by establishing a culture where they feel safe raising problems and attempting to solve them."

"I use the facilitation skills I developed as a Lead daily," says Sylvie. "During discussions with the interprofessional team I'll ask 'why' many time  to better understand the process, and when we can't agree on a solution I asked them to pause, step back and think differently."

Lessons from the front lines

Stephen Casey, Educator, Emergency Department, Toronto General & Former Lean Lead says: "Lean, at its core, is about making common sense a priority. It simplifies the seemingly complicated."

Stephen's Top 3 Lean Lead Learnings:

  1. People want to be challenged. Give them the tools and the opportunity and they will want to challenge the status quo.
  2. Sending an email won't solve a problem. Leaders need to commit to a standard and show it is important by talking about it every day.
  3. Show results in real time. People care about doing well, and they want to see they are making progress over time, beyond the day to day. 

Stephen Casey
Stephen Casey, uses the skills he developed as a Lean Lead in his new role as the educator for the Toronto General Hospital Emergency Department. (Photo: UHN)

Sylvie demonstrated the value of that approach not long after stepping into her new role. The physiotherapy team on the unit believed the rehab gymnasium wasn't large enough for them to safely treat patients. Costly renovations were being considered to solve the problem. Instead, Sylvie challenged the team to rethink how they were using the space.

"As a physiotherapist, I had personal experience with the team's problems," says Sylvie. "It gave me some insight and credibility that a consultant wouldn't have. I helped them define the problems they felt were due to insufficient space."

With a clear understanding of what needed to change in the gym, the team spent several days reorganizing and removing unnecessary equipment. They were so satisfied with the result that the $50,000 renovation was avoided.

"We are so happy with the support we got for this project and proud of what the team accomplished," says Heather Preston, physiotherapist, musculoskeletal rehabilitation, Toronto Rehab.

Leads also gain exposure to much more of the broader organization than they would in a clinical role.

Fellow former Lean Lead and current manager at Toronto General Hospital, Marleine Elkhouri, says her exposure to the patient flow perspective taught her the importance of understanding processes at all stages in the patient journey.

Sylvie Robinson
Sylvie Robinson, Program Manager, Toronto Rehab, says "I use the facilitation skills I developed as a Lead daily." (Photo: UHN)

"We need to talk to other departments to understand how our and their processes affect patient care so we can resolve issues as they arise," says Marleine. "That conversation can't be high level, we'll get together with another department and walk through a process step by step. Using that approach, solutions to complex problems often becomes obvious."

The former Lean Lead sees herself as a coach. She fosters an atmosphere where staff feel comfortable making problems transparent, then coaches them through the circle of continuous improvement to ensure they are addressing the root cause of a problem.

"When a staff member raises a problem we start by tracking how often it happens and what causes it," says Marleine. "I challenge them to collect data before and after we implement a solution to see if it worked. You need facts to show a gain. If the problem doesn't come back we know it was solved, and if it does we can try again. It takes longer, but it's very satisfying knowing we got it right."

Lean thinkers embrace the concepts of transparency and continuous improvement. The Lean Lead role has demonstrated that when leaders combine their experience with the Lean skills of facilitating, coaching and problem solving, they provide a solid foundation for organizations to deliver the safest, highest quality care possible. In short, transformation happens.

If you'd like to learn more contact the UHN Lean Team at

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