YOU ARE DOWNLOADING DOCUMENT

Please tick the box to continue:

Transcript
Page 1: TWI in Healthcare

13 September 2015

TWI Institute Patrick Graupp, Senior Master Trainer

www.TWI-Institute.org

TWI in Healthcare

Revolutionizing Health Care with Time-Proven Principles

Page 2: TWI in Healthcare

TWI Helped Win WWII

• With a gun to their heads (literally), the TWI founders had to find solid principles of human nature that:

– Work every time

– Inspire dedication

– Create performance results

– Build leadership

– Strengthen teamwork

2

Page 3: TWI in Healthcare

3

Impact of TWI on the War Effort

Of the 600 client companies monitored by the TWI

Service throughout the war:

86% increased production by at least 25%

100% reduced training time by 25% or more

88% reduced labor-hours by over 25%

55% reduced scrap by at least 25%

100% reduced grievances by

more than 25%

Page 6: TWI in Healthcare

“If people want to succeed with lean or TPS they have to emphasize people development and making leaders capable of delivering improvements. TWI is a great starting point even today and a hidden strength of Toyota’s production system.”

Benchmarking with Toyota

Source: ”Why in your opinion is TWI critical?” Summary Notes from Art Smalley Interview with Mr. Isao Kato, TWI Influence on TPS & Kaizen, Feb. 8, 2006, www.ArtofLean.com

6

Page 7: TWI in Healthcare

Today Reaching the Global Market

7

Nigeria

China

Malaysia

Italy

Page 8: TWI in Healthcare

Basic Needs of Good Supervisors

Work

ResponsibilitiesKN

OW

LED

GE

SKIL

L

Instructing

ImprovingMethods

Leading

Safety

8

Page 9: TWI in Healthcare

Skill in Instructing Job Instruction

Training

Skill in Improving Methods Job Methods

Training

Skill in Leading Job Relations

Training

Three Training Programs for Three Skills

9

Page 10: TWI in Healthcare

The three TWI programs work together like a three-legged stool — take one leg away and the stool falls down.

• JR – Motivated people

• JI – Standard work

• JM – Continuous Improvement

10

Synergy Between the Three Skills

Page 11: TWI in Healthcare

Job Instruction Training (JI)

How to teach people to quickly learn to do a job correctly, safely, and conscientiously.

11

In Japanese, “The WAY to Teach Jobs”仕事の教え方 = Shigoto no Oshie-KATA

Page 12: TWI in Healthcare

JI 4-Step Method

Step 1 - Prepare the WorkerGet the person interested in learning the job

Step 2 - Present the OperationDon’t give them more information than they can handle at one time

Step 3 - Try-out PerformanceContinue until you know they know

Step 4 - Follow-upEncourage questions

”If the worker hasn’t learnedthe instructor hasn’t taught.”

12

Page 13: TWI in Healthcare

No. __________

JOB INSTRUCTION BREAKDOWN SHEET

Operation: ____________________________________________________

Parts: ________________________________________________________

Tools & Materials: ______________________________________________

REASONSKEY POINTSIMPORTANT STEPS

Reasons for key points

Anything that might—1. Make or break the job2. Injure the worker

3. Make the work easier to do, i.e. “knack”, “trick”, special timing, bit of special information

A logical segment of the operation when something happens to advance the work

People learn better when they know why they do it that way.

The 5 or 10% of a job that represent the hard or tricky parts.

Not a micro-motion study of the job.

What How Why

Page 14: TWI in Healthcare

Job Relations Training (JR)

Trains supervisors/team leaders on how to evaluate and take proper actions to solve and to

prevent problems with people.

14

In Japanese, “The WAY to Handle People”人の扱い方 = Hito no Atsukai-KATA

Page 15: TWI in Healthcare

JR 4-Step Method

DEFINE YOUR OBJECTIVE

Step 1 - Get The FactsGet the whole story (opinions & feelings)

Step 2 - Weigh And DecideDon’t jump to conclusions (possible actions)

Step 3 - Take ActionDon’t pass it off to someone else

Step 4 - Check ResultsDid your action help production?

DID YOU ACCOMPLISH YOUR OBJECTIVE?

15

Page 16: TWI in Healthcare

• Let each worker know how he/she is doing

• Give credit when credit is due

• Tell people in advance about changes that will affect them

• Make the best use of each person’s ability

Foundations for Good Relations

16

Supervisor

A supervisor gets results

through people

Production

Costs

SafetyQuality

Maintenance

Training

People

Jo

b

Rela

tio

ns

Page 17: TWI in Healthcare

Job Methods Training (JM)

Trains supervisors/team leaders on how to analyze jobs to make the best use of the people,

machines, and materials now available.

17

In Japanese, “The WAY to Do Kaizen”改善の仕方 = Kaizen no Shi-KATA

Page 18: TWI in Healthcare

Job Breakdown Sheet

PRODUCT: MADE BY: DATE: OPERATIONS: DEPARTMENT:

REMARKS IDEAS

PRESENT/PROPOSED METHOD DETAILS

Dis

-

tance

TIME/TOLERANCE/ REJECTS/SAFETY

WH

Y

WH

ER

E

WH

EN

WH

O

HO

W

Write them down, don’t try to remember.

Elim

ina

te

Co

mb

ine

Re

arr

an

ge

Sim

plif

y

JM 4-Step Method

Step 1 – Breakdown the Job

Step 2 – Question Every Detail

Step 3 – Develop the New Method

Step 4 – Apply the New Method

18

Page 19: TWI in Healthcare

JM Breakdown Analysis

Page 20: TWI in Healthcare

Questioning the Details Brings Out Ideas for Improvement

Why?

What?

Where?

When?

Who?

How?

Eliminate

CombineRearrange

Simplify

20

Page 21: TWI in Healthcare

TWI in Hospitals and Health Care

21

Cleaning &

Sterilizing GI

Scope

Electronic records

Ebola

Blood Cultures

Urine specimen collection:

Foley

Central Line

Dressing Change

OR

Page 23: TWI in Healthcare

Breakdown Sheet BEFORE 10-hour Class

23

JOB BREAKDOWN SHEET DATE: January 21, 2008 TEAM LEADER: Donna S., Gillain A., Joan C. SPONSOR: Donna S., MD

AREA: All areas providing direct pt care or in contact with pt care supplies, equipment or food

JOB: Hand Hygiene in compliance with CDC & WHO hand hygiene guidelines

WRITTEN BY: Joan C.

MAJOR STEPS KEY POINTS REASONS FOR KEY POINTS Step #1: Identify the need for clean hands

Remove artificial fingernails or extenders when in direct contact with pts or their environment

Artificial nails house germs that can be passed on when you touch pts

Clean hands whether or not you use gloves (i.e. before putting on gloves & after removing gloves)

Gloves are not a substitute for cleaning hands because gloves don't completely prevent germ transmission

Before direct contact with pt, pt's environment or equipment

Protect the pt against harmful germs carried on your hands

After direct contact with pt, pt's environment or equipment

Protect yourself & the health-care environment from harmful pt germs

Step #2: Inspect your hands to determine best cleaning method

If not visibly soiled, use alcohol-based gel Cleaning with gel is faster, more effective, and better tolerated by your hands

Visibly soiled hands or hand with fecal contamination require washing with soap & water

Dirt, blood, feces or other body fluids are best removed with soap & water (C. diff spores are not killed with alcohol-based gel)

Step #3: Use enough product to cover all hand surfaces & fingers

GEL: Cover all surfaces with a thumb nail-sized amount

Friction & skin contact are required to remove germs

WASH: Wet hands with water, wash with enough soap to cover all hand/finger surfaces

Step #4: Spend enough time cleaning your hands

GEL: Vigorously rub until product dries on your hands

Antiseptic action is not complete until fully dried (approx 15 sec.)

WASH: A minimum of 15 sec. (the length of singing "Happy Birthday to You")

As least 15 sec. is needed to ensure complete coverage of hand surfaces

Use paper towel to turn off water faucet

Prevent transfer of germs from faucet onto clean hands

Step #5: Let your hands completely dry

Moisturize hands with lotion available through Central Supply

To minimize contact dermatitis without interfering with antimicrobial action

Put on gloves after hands are dry Skin irritation may occur if moist hands come in contact with glove material

Step #6: Perform task with clean hands

Task is done immediately after cleaning hands You may be distracted & touch unclean surface with clean hands

Page 24: TWI in Healthcare

Breakdown Sheet AFTER 10-hour Class

IMPORTANT STEPS KEY POINTS REASONS

A logical segment of the operation

when something happens to

advance the work.

Anything in a step that might—

1. Make or break the job

2. Injure the worker

3. Make the work easier to do, i.e. “knack”,

“trick”, special timing, bit of special

information

Reasons for the key points

1.Wet hands Without soap Soap rinses away

2. Apply soap Cover all surfaces Kill all germs

3. Rub hands1. Palm to palm

2. Palm to backs

1. Clean entire surface

2. Clean entire surface

4. Run fingers

1. Thumbs

2. Interlocking

3. Backs of fingers to palm

4. Tips of fingers to palm

1. Most active part of hands

2. Sides of fingers cleaned at one time

3. Cuticles and knuckles

4. Under finger nails

5. Rinse hands Leave water on Prevent recontamination of hands

6. Dry Use towel to turn off water 1.Prevent recontamination of hands

24

Page 25: TWI in Healthcare

Trouble with IV Starts at Baptist Memorial

• Low percentage of first starts causing patient discomfort

• Nurses give up on difficult patients

• Many see a difficult patient and don’t even try: “Call Hannah or Nikki!”

• Two training nurses are continually interrupted to start difficult patients

25

Page 26: TWI in Healthcare

Breakdown Sheet for IV

Start

26

No. ________

JOB INSTRUCTION BREAKDOWN SHEET - HEALTHCARE Task: Obtaining IV Access_______________________________

Supplies: Tourniquet, CHG, Needle, Tegaderm, Connector, Flush

Equipment & Materials: __________________________________

IMPORTANT STEPS KEY POINTS REASONS

1. Prepare site

1. Apply tourniquet 3-6 inches above

2. Disinfect with chlorahex

3. Apply Ethyl Chloride Spray

1. To distend the veins 2. To prevent infection 3. To numb site

2. Stick Vein

1. Stabilize vein 2. Steady hand with

2-3 fingers 3. Bevel up 4. Hold needle at 45

degrees

1. To prevent vein from rolling

or moving 2. To improve accuracy of the

stick 3. Ease of flow 4. Appropriate angle to

puncture the vein

3. Advance Needle

1. Lower to 10 degrees

2. Assure flashback 3. ¼ to 1/3 of its

length

1. To ensure that you don’t go through the vein

2. To verify that you are in the vein

3. To keep catheter in correct position and prevent kinking

4. Thread Catheter

1. Slide with index finger

2. Hub touches skin 3. Hold pressure at

catheter tip

1. Creates a smooth glide for the catheter to enter the vein

2. To ensure proper placement 3. To prevent bleeding out of

site

5. Remove and retract needle

1. Press safety when needle is in hub

1. To prevent needle sticks

6. Connect and Secure

1. Seat hub / screw tightly

2. Remove tourniquet 3. Flush and Dress

1. To prevent unnecessary bleeding and leaking at site

2. Relieves pressure 3. Verifies patency and

protects from germs

Page 27: TWI in Healthcare

TWI Breakdown Identifies Skill

• Stick Vein• Hold needle

at 45 degrees• Advance Needle

• Lower to 10 degrees

27

Page 28: TWI in Healthcare

Attacking Hospital Acquired InfectionsHospital Infections Cost Billions. Despite widespread implementation of quality improvement initiatives, an estimated $9.8 billion is spent each year treating hospital-acquired infections (HAIs), according to a study published online September 2 in JAMA Internal Medicine. Sep 3, 2013

28

Page 29: TWI in Healthcare

No. ________

JOB INSTRUCTION BREAKDOWN SHEET - HEALTHCARE Task: Scrub the Hub

Supplies: Gloves, Alcohol wipes, Alcohol caps

Equipment & Materials: NONE

IMPORTANT STEPS KEY POINTS REASONS

A logical segment of the operation when something happens to advance the work.

Anything in a step that might – 1. Make or break the job 2. Injure the worker 3. Make the work easier to do, i.e.

“knack”, “trick’, special timing, bit of special information

Reasons for key points

1. Enter & Introduce

1. Explain procedure

2. Wash hands and glove

1. Patient confidence

2. Protect against germs

2. Remove connected device

(no key points)

3. Clean top & threads for 15 seconds

1. Downward pressure with thumb

2. Side pressure with forefinger

3. Rotating left & right 15 times

4. Complete surface

1. Get into crevice of full circumference

2. Get into groves

3. Scrape out all germs

4. All the way around the hub

4. Air dry & connect device

1. 15 seconds 1. To kill the

germs

#255

Preventing Infections at Baptist Health Care

“Earlier this week the Surgical ICU at Baptist celebrated 60 consecutive days without a patient being infected from a central line. It is no coincidence that this occurred immediately following your hard work on getting staff trained using job instruction for hand hygiene and scrubbing the hub of central line catheters.” (28 July 2016)

Wanda Kaye Hambrick BSN MBAVice President, Quality and Patient SafetyBaptist Health Care Inc.

Page 30: TWI in Healthcare

UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay.

Catheter-associated Urinary Tract Infections (CAUTI)

30

Page 31: TWI in Healthcare

No. ________

JOB INSTRUCTION BREAKDOWN SHEET Operation: Catheter Care Parts: CHG wipes, bath wipes, towel Tools & Materials: gloves

IMPORTANT STEPS

KEY POINTS REASONS

1. Preparation 1. HH & gloves 2. AIDET

1. Decrease risk of infection 2. Courtesy, set expectation

2. Ask permission 1. Explain what & why 2. Provide privacy

1. Know what visit is for and set expectation

2. Courtesy, prevent embarrassment

3. Clean perineal area & towel dry

1. Front to back, down each side

2. Down center w/fresh wipe 3. Under sides/thighs 4. Under folds/in pockets 5. Male: replace foreskin

1. To 4. Decrease risk of infection 5 Comfort

4. Clean catheter from insertion site

1. Release from statlock holding at insert site

2. Rolling away from patient Instructor note: (wiping with a rotating motion away from patient)

1. Stability of catheter & clean entire length of catheter

2. Clean contaminants away from insertion site

5. Disinfect surrounding area

1. Change gloves 2. Under, sides, thighs 3. Avoid cuts, abrasions

1. First gloves will be soiled from initial patient cleansing

2. CHG is used to disinfect under folds of skin and on skin that would have contact with catheter leaving in place a film of CHG that will continue to fight infection

3. CHG is meant for intact skin, could cause irritation to cuts or abrasions

6. Disinfect catheter

1. Avoid insertion site 2. Holding at insertion site 3. Away from patient 4. Change statlock if

necessary 5. Secure catheter

1. CHG stings on mucous membranes 2. So you do not pull the catheter 3. To wipe germs away from the

patient 4. Cleanliness and prevent skin

breakdown 5. To prevent pulling and reduce

discomfort for the patient

7. Reposition patient & bed

1. Remove gloves 2. HH

1. & 2. Decrease risk of infection

Breakdown Sheet for

Catheter Care

31

Page 32: TWI in Healthcare

The first step in creating lean processes is to achieve a basic level of process stability.

- The Toyota Way Fieldbook, Jeffrey Liker & David Meier, 2006, p56

Knowing that jobs are always done the same way helps to establish a predictable process before going too far down the path with the other elements of standardized work such as machine up time, availability of material, flow, and takttime.

- Art Smalley, Basic Stability is Basic to Lean Manufacturing Success

The Need for Stabilized Processes

32

Page 33: TWI in Healthcare

Time

Event #1

Event #2

What Standard should be

Things go back to

where they were before

the change when

people are not trained

and work to standard.

0 Maintenance

0 Maintenance

Event #3

Current Method

What Standard should be

Outcome of Tactical Lean

33

Page 34: TWI in Healthcare

JI – Document current best methods to retrain people to a standardJR – Build trust so people are willing to follow instructionsJM – Engage people in improvement to breakdown barriers to change

Achieving Basic Stability

Time

Job Instruction Job Relations

Predictable process

Variation

Job

Met

ho

ds

34

Page 35: TWI in Healthcare

Lean Activity with TWI

Time

Lean Tools

Standard Work

New Standard

Stabilized Processes - JI

Positive Environment - JR

Safe Environment - JS

Current Practices

Gradually Improve - JMTWI as an

integral part of

Lean Strategy

Output

35

Page 36: TWI in Healthcare

THANK YOU VERY MUCH

The TWI Workbook: Essential Skills for

SupervisorsProductivity Press, Shingo Prize 2007

Patrick Graupp and Robert J. Wrona

Implementing TWI: Creating and

Managing a Skills Based CultureCRC Press, October 2010

Patrick Graupp and Robert J. Wrona

Getting to Standard Work in Health Care: Using

TWI to Create a Foundation for Quality CareCRC Press, October 2012

Patrick Graupp and Martha Purrier

Building a Global Learning Organization:

Using TWI to Succeed with Strategic

Workforce Expansion in the LEGO GroupCRC Press, June 2014

Patrick Graupp, Gitte Jakobsen & John Vellema


Related Documents