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Archive for January, 2010

TWI JI in Healthcare – beyond checklists.

I’m reading The Checklist Manifesto by Atul Gawande. In it the author makes the case for checklists even when the person doing the task is a recognized expert. The most common example is, of course, the airplane pilot’s checklists.  They were developed after the disastrous test flight of the first B-17 in 1935. The failure to unlock certain controls made it clear that one oversight could be fatal in a multifaceted operation such as flying a complex airplane. In his book, Gawande argues in favor of the use of similar checklists for medical professionals, in particular surgeons, for whom the operating suite has become a complex workplace populated by many specialists and yet, where one misstep could be disastrous. 

 Our interest in Gawande’s work stems from the work we are doing to bring TWI back to healthcare. TWI should be a major contributor to Lean successes in healthcare and in the process, significantly improve patient care, much like Gawande’s checklists do. In fact when you think about it, TWI is grounded in the use of checklists. Checklist cards for supervisors and checklists of  important steps and key points for trainers.  I brought this to Bob Wrona’s attention and he reminded me of the ground breaking work being done at Virginia Mason Medical Center in Seattle.  There they have accomplished so much using TWI JI that  I asked him to summarize that story for our blog and here it is. 

Steve Grossman – Director

 The VMMC TWI Story:

Bob Wrona

 I watched as Richard Abercrombie delivered JI and JR at the Virginia Mason Medical Center (VMMC) in Seattle for the TWI Institute in March 2009. I took note of the enthusiasm of the ten participants who had been carefully selected to participate in Richard’s class. They were all prepared and eager to learn. Each was asked to select a problem area for their JI class demonstration. I was surprised that the problems areas were seemly simple: Hand Hygiene; Hand Washing; 6 Point Hourly Rounding; Collecting a Specimen; Blood Glucose Monitoring; Removing a Saline Lock; Donning and Removal of Gown and Gloves; Placement of Patient ID Band; Stool Occult Blood Testing and; Emptying an Ostomy Bag. But, these were areas that were causing a great of problems for the patients and staff.

 I must say it was incredibly exciting to see Patient Care Technicians and Registered Nurses get excited about how JI can help them to “standardize” these daily activities to improve patient care. I was equally excited to count 35 people that observed the class.  They included doctors, surgeons, head nurses, and administrators who set aside two hours of their busy schedules to evaluate the TWI training.

 VMMC got to this point over a long period of concerted effort to create a Leaner healthcare organization. In 2002 they adopted the Toyota Production System.  They now have a well deserved reputation for leadership in Lean healthcare.  Along the way, VMMC got to the point in their lean journey where they struggled to sustain the many gains recently made. Recognizing the slip in results, Linda Hebish and Martha Purrier, who manage the VMMC Kaizen Promotion Office, created a survey for staff to identify needs in staff development.   Standard work and training people more quickly, rose to the top. They searched for an answer and found TWI.

 Fast forward to May 2009, just a little more than a month after I left Seattle and I’m watching Martha make a presentation at the TWI Summit in Cincinnati, Ohio. Her enthusiasm is, if anything, higher than in March. She shared the following initial results with the audience:  

  • The audited reliability for Hand Hygiene and Personal Protective Equipment for trained staff was now over 90%.
  • The reception of training from Staff and Trainers has been very positive. “We are really grateful to know the right way.”
  • Development is underway for this training to be incorporated into general orientation.

 She repeated comments from two nurses and one patient.

 “For a long time now, I’ve taught my staff that the majority of patient falls occur during the toileting process.  Knowing, however, wasn’t enough to hardwire actions to prevent patient falls.  TWI provides the hardwiring and rigor … toileting is planned for and built into my staff’s work flow.  It’s really made a difference on Level 8.”

 “Recently I entered a patient’s room on Level 10.  From her bed, this patient watched me wash my hands.  The patient remarked, “That is so interesting!  EVERYBODY coming in here washes their hands the exact same way!  I’ve never seen anything like it!”  

 “ You know… you all must go through some kind of special training because EVERYONE asked me if I was comfortable, offered the bathroom, made sure that I had my call light and phone, and then asked if there was anything else I needed. I’ve never seen such great customer service while in a hospital.”

 Since that presentation Martha and one of her staff attended the 40-hour JI Train the Trainer with Patrick Graupp (September 2009). They can now do their own training to meet the growing demand for JI. Once they train leaders to train, the results are dramatic. In one nine week period 467 RNs and PCTs were trained to do three strategic jobs using the standard methods. She is also reporting pull for training from other departments including:

  • Transporters
  • Out Patient Clinics
  • Hospital nursing units not part of trial (ED, RHU, CCU)
  • Pharmacy
  • Sterile Processing
  • GME and Patient Safety Curriculum Team
  • MD Section Heads and Surgeon Group

 The enthusiasm and the results continue to be outstanding.  So much so, that the Society for Health Systems (SHS) and ASQ  invited Martha, Patrick Graupp and I  to conduct a 4-hour pre-conference workshop at their Conference in Atlanta, February 24, 2010.

 Bob Wrona is the Executive Director of the TWI Institute

Communicating the Return on Investment of TWI Job Methods and Problem Solving to Decision Makers

Pat Boutier has kindly agreed to share a simple method he uses for communicating return on investment (ROI) to his customer when he delivers Job Methods (JM) and Problem Solving (PS).  Can you share any methods you use?  You may do so in the form of a comment below or an email to me to be posted here. 

Pat said:

In my role as a Business Specialist at the Texas Manufacturing Assistance Center (TMAC) I often assist companies by providing TWI training.  Each time I find the classes, whether, Job Relations (JR), Job Instruction (JI), Job Methods (JM), Job Safety (JS) or Problem Solving (PS), to be of immediate and measurable benefit to my customers.

Generally, though not always, I am teaching these classes to individuals who are not at the ‘top’ of the organizational pyramid, such as it might be.  Those who have participated are always providing me with feedback that talks about how their participation has opened their eyes  to many new possibilities and have already begun to create and / or implement change that is beneficial to the company.

So what can I do to insure that my “customer”, those individuals who make decisions, learn about the impact that my work with their teams has made?

One item, of course, is the evaluation form that I use with all of the TWI classes.  But just using that form and providing copies to a manager is simply asking for a lack of involvement.  What manager is going to take the time to read that many comments?  So I take those evaluations and summarize them into a simple excel sheet, which provides the numbers and all the comments.  All of this in a one page form.  That generally allows the manager to at least glance at it and see the general input from his own people.

I’ve found this effective in getting the opportunity to discuss more opportunities to effect further change.   But this still leaves me with the problem that my customer would relish a more quantified input that the work we did actually resulted in quantifiable ROI at least in the short term.

JM and PS provide that opportunity. These programs require that the participants create a ‘proposal’ sheet.  Within this sheet we have the participants briefly describe the current state and the future state. We then suggest how to apply monetary values to this work.

So, right before our eyes, is the answer to supplying a decision maker with the estimated impact their TWI trained employees can have.   I simply require each individual to fill out that proposal form and hand it to me before the end of the last session.  (In some cases I allow them to email it to me).

With this information I now can create a brief memo listing the ideas for improvement, and the dollar impact each is likely to have on the business over a one year period.  Immediately, I can have a discussion on impact, the value of which is rarely refuted because their people provided the information. What better way to discuss ROI with a customer?

Of course, the manager might talk about some ideas being impractical, or even say that the financial advantage is overstated, I don’t care, because the goal is to talk about potential impact and positive changes that can be attributed directly to TWI.

 Here is a sample of a chart in the memo that follows a JM Class:

Job Methods at XYZ Inc.   January  25th -29th, 2010
Projects that were identified in the10 hour JM training.    
Yearly Savings Project Owner Improvement
 $            9,500 Joe Bidden Create a Jig for plate welding
 $            5,600 Moriah Carey Move inventory to point of use in Cell C5
 $            7,500 Tom Jones Eliminate Step 3 in electroplating process
 $          12,000 George Washington Simplify wiring harness on model A123EF
 $          13,500 Donna Karan Hang air guns at each workstation
 $          12,500 George Lopez etc.
 $            8,500 Sarah Palin etc.
 $          16,300 Edward Deming etc.
 $          18,000 Albert Einstein etc.
 $            4,700 Manny Ramirez etc.
 $        108,100 Total savings year one  


Pat Boutier, Business Specialist at TEXAS MANUFACTURING ASSISTANCE CENTER (TMAC) at The University of Texas at Arlington, has 30 years of technical and business experience. He works with companies in implementing and increasing their deployment of Lean Enterprise techniques working with processes that cover a wide variety of equipment and services and is also a Shingo Prize Examiner. Pat has been certified by the TWI-Institute (Training Within Industry) as a trainer for Job Relations, Job Instructions, Job Methods, Job Safety and Job Problem Solving and has completed the Black Belt in Lean Six Sigma with the George Group. In addition he has the Bronze Certificate in Lean, and is a certified RFID implementer along with being a National MEPU RFID trainer.

Steve’s email for your story is

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