13 September 2015
TWI Institute Patrick Graupp, Senior Master Trainer
www.TWI-Institute.org
TWI in Healthcare
Revolutionizing Health Care with Time-Proven Principles
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
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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%
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Hospital Adaptation of JI during WWII
• Endorsed by Mayo Clinic
• Kenney treatment of infantile paralysis
• Maryland Workshop for the Blind
• Red Cross Home Nursing
• Numerous other hospitals across the U.S. used the JI program to successfully train ward helpers to take over routine duties of nurses that were in short supply.
TWI Goes to Japan
Toyota embraced TWI in 1951 to train their people in the evolving Toyota Production System and remains a cornerstone of their team leader training and standard work today
Taiichi OhnoFounder of the Toyota Production System (TPS)
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“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
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Today Reaching the Global Market
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Nigeria
China
Malaysia
Italy
Basic Needs of Good Supervisors
Work
ResponsibilitiesKN
OW
LED
GE
SKIL
L
Instructing
ImprovingMethods
Leading
Safety
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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
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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
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Synergy Between the Three Skills
Job Instruction Training (JI)
How to teach people to quickly learn to do a job correctly, safely, and conscientiously.
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In Japanese, “The WAY to Teach Jobs”仕事の教え方 = Shigoto no Oshie-KATA
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.”
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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
Job Relations Training (JR)
Trains supervisors/team leaders on how to evaluate and take proper actions to solve and to
prevent problems with people.
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In Japanese, “The WAY to Handle People”人の扱い方 = Hito no Atsukai-KATA
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?
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• 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
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Supervisor
A supervisor gets results
through people
Production
Costs
SafetyQuality
Maintenance
Training
People
Jo
b
Rela
tio
ns
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.
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In Japanese, “The WAY to Do Kaizen”改善の仕方 = Kaizen no Shi-KATA
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
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JM Breakdown Analysis
Questioning the Details Brings Out Ideas for Improvement
Why?
What?
Where?
When?
Who?
How?
Eliminate
CombineRearrange
Simplify
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TWI in Hospitals and Health Care
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Cleaning &
Sterilizing GI
Scope
Electronic records
Ebola
Blood Cultures
Urine specimen collection:
Foley
Central Line
Dressing Change
OR
Hand Washing Pilot atVirginia Mason Medical Center, Seattle WA
• 80% of staff was trained in the new JI hand washing method.
• 467 RNs and PCTs were taught 3 strategic jobs in 9 weeks.
• Hand Hygiene reliability went from 83.5 use (as low as 40% worldwide) to >98%.
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Breakdown Sheet BEFORE 10-hour Class
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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
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
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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
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Breakdown Sheet for IV
Start
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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
TWI Breakdown Identifies Skill
• Stick Vein• Hold needle
at 45 degrees• Advance Needle
• Lower to 10 degrees
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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
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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.
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)
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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
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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
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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
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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
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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
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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