Knowledge of LEAN methodology tools allowed me to focus on a project that will create a culture that enables sustainable improvement at an organizational level. More specifically, build on the success of the implementation of a daily continuous improvement program (DCIP) in a large pediatric ambulatory portfolio enabling growth for further improvements. I was able to directly apply my new process improvement skills in assessing the current state of the DCIP program. The assessment identified several areas for improvement to focus on. In the literature, managers are recognized as the linchpins in sustaining improvement. In the clinical setting, teams that functioned well in DCIP had a clear vision with strong leadership and champions to sustain the gains. Performing a key stakeholder analysis with the ambulatory managers and their executive added another perspective that highlighted a need to gain a clearer understanding of the manager role and the challenges they experience. As a result of the analysis, an audit of the nurse manager role was completed using a validated nurse manager audit toolkit. The audit results were used to inform and stimulate discussion in a focus group with key stakeholders and included an activity to establish the priorities for the role. Common themes emerged which really identified opportunities for restructuring the manager role. Utilizing best practices and LEAN process improvement tools the approach undertaken was to adopt a High performance management System (HPMS) using a LEAN visual management tool to build an infrastructure that would enable managers to sustain the improvements. The really exciting, and innovative aspect in the project was creating the OBEYA, which translates as "big room" in Japanese. This is a LEAN visual management tool that is housed in a big room with four distinct walls. Each wall has a specific purpose that enables a culture to allow managers to "see together, learn together and act together". The strategy wall creates a clear visual of the program goals and objectives that are directly aligned with the organizational strategy. The project wall flows to the right of the strategy wall and clearly outlines the projects directly related to each organizational strategy- the use of colour coding is key in training the viewer to see the most important details such as the progress of projects and timelines/targets for completion. The portfolio wall clearly outlines each key performance metric and its priority. Colour coding is used to provide a quick visual of how each team are performing.

The primary focus of my fellowship term was to develop my skills in leadership, coaching and facilitation in process improvement. The RNAO fellowship allowed me dedicated time away from clinical duties to read relevant literature and understand the LEAN Theories and tools used in process improvement. My increased comfort and knowledge base was made possible as a result of a combination of mentorship from leaders and experts in process improvement, and participation in LEAN training which secured me certification as a LEAN yellow belt and as a Daily continuous improvement Process (DCIP) facilitator. Since becoming certified, I have been able to co facilitate two of the DCIP facilitator training modules. I am now also pursuing my green belt LEAN training and applying the knowledge and skills I have acquired to inform future projects. For example, now I only work on projects that I create A3 project charters and standard work for to reduce the variation in how a project is implemented across the portfolio. I am also sharing the tools and coaching staff how to follow the same process. My increased skills have prepared me in leading a large project which will create a culture for sustaining improvement within the ambulatory portfolio and possible expansion to all tiers of management within the organization.

One of the projects that the OBEYA tool helped managers to prioritize and focus on is a communication tool called the "care card". It is a communication tool that aids in the transfer of knowledge and education between the family and the healthcare provider during their clinic visit. This tool is directly linked to the patient satisfaction key performance indicator and early results obtained from family experience surveys collected have yielded a high percentage of positive feedback. I co led and provided structure for this project through the creation of a project charter and standard work. With the increased focus and collaboration experienced by managers these PDSA tools allowed managers to share the projects details and work involved easily, thereby eliminating and reducing variation while facilitating seamless knowledge translation across different clinics.

Early Outcomes of the HPMS framework adoption reported from managers in the pilot stage were positive and already managers' report a new found ease and ability to focus on the priorities and most importantly directly track the metrics as they relate to each project they are managing. They comment on the increased collaboration and efficiency as the visual management tool (OBEYA) allows them to clearly see and strategize for solutions. Managers identified early on in establishing priorities for their role that individual managers have different specialized levels of expertise and tend to excel in certain areas. With this in mind a restructuring of governance for certain key organizational strategies was undertaken matching their skillset. This approach creates a structure for expert knowledge translation across the portfolio in a seamless way. This restructuring technique will allow a greater span of control and it is anticipated it will reduce variation as standard work is created across settings

The primary focus of my fellowship term was to develop my skills in leadership, coaching and facilitation in process improvement. The RNAO fellowship allowed me dedicated time away from clinical duties to read the literature and understand the LEAN Theories and tools. My robust group of mentors were so helpful and supportive and really guided in in the right direction. I built very positive relationships from these opportunities and highly recommend finding the right mentors as they are pivotal in your success. A special thank you to Stephanie Lappan- Gracon and Melody Hicks who supported me every step of the way through the application process to completion and Ali Shahzada who really hit the nail on the head from the very beginning with his coaching sessions and Mary McAllister who acted as a great sounding board, while also editing and reviewing submissions for me for publication. The really exciting, and innovative aspect in the project was creating the OBEYA, which translates as "big room" in Japanese. This is a LEAN visual management tool that is housed in a room with four walls. Each wall has a specific purpose that enables a culture to allow managers to "see together, learn together and act together’’. Another memorable event in the fellowship was attending a workshop titled "effective communication and Presentation skills' facilitated by an expert in communication. This workshop provided me with many tools and key lessons in presenting my project which I have already used when conducting a focus group session- the Feedback I received from the key stakeholders was overwhelmingly positive. Some ideas I took home include creating a story file of personal stories you can pull from to use in your presentations as your audience will more often remember a story that is well delivered and it engages them in a meaningful way.

When you are performing clinical duties every day, it's not always possible to be creative in a meaningful impactful way. Researching this tool and using my creative talents was a real pleasure and a wonderful realization that potentially within everyone resides untapped talents that can be unleashed.