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Let My People Grow –the TWI Method in Healthcare
Mark Graban, MS, MBA
Peter Patterson, MD, MBA
Agenda
• Origins of TWI in Healthcare
• The J Programs in WWII & Modern Day
– Job Instruction
– Job Methods
– Job Relations
• Case Example: Yuma Regional Medical Center
Henry Ford - 1922“In the ordinary hospital the nurses must make useless steps.
More of their time is spent in walking than in caring for the
patient.
This hospital is designed to save steps… we have tried to
eliminate waste motion in the hospital.”
3
Origins of TWI
• Problem:
– Too many factory workers sent overseas to war
• Too many new workers
– Need for increased production of war material
• New workers + Increased demand = ??
• Countermeasure:
– Government program called Training Within Industry
What is TWI? The “J Programs”
• Job Instruction– How to effectively train new workers
– “If the worker hasn’t learned the instructor hasn’t taught.”
• Job Methods– How to improve processes
• Job Relations– How to manage / supervise workers
– “People must be treated as individuals”
• Deliveries of supplies delayed because of improper ordering
• Articles returned by other departments because they were not made correctly
• Employees have difficulty in handling new-type equipment
• Limited storage space (linen and supplies) not properly used
• Safety equipment not being used
• Correct procedures not followed
• Employees leave to go to other hospitals
Use of JI in Hospitals
American Journal of Nursing, March 1944
Learn by Shadowing (???)
Job Breakdown Sheet (WWII)“Key
Points”
Job Breakdown Sheet (2007)
Structured Use of JBS to Train
1. Prepare the worker
2. Present the operation
3. Try out their performance
4. Follow up their work
Finding Waste in Hospitals
Use of JM in the Hospital (WWII)
Job Methods Case (WWII)
• Problem: Too many clerk walking trips
– Countermeasure: Install pneumatic tube? NO
– Countermeasure: Eliminate, combine, and rearrange jobs
• Results:
– # of trips from 29 to 10
– Saved 190 minutes / day
Modern Use of Job Methods
Identifying Waste – Dr. Tebbetts
1. Can I eliminate this step?
2. Can I combine this step with another step or steps?
3. Can I rearrange the steps to make the flow shorter or smoother or both?
4. Can I simplify the step?
5. Can the changes be made without any sacrifice of quality?
• For each step, ask
Identifying Waste – Dr. Tebbetts
• Is this technique or event causing surgical trauma? If so, how, and can it be modified ?
• Is this technique, instrument, or event causing any bleeding whatever? If so, how, and can it be modified?
• For each method, ask
Problems with Supervision
• Best worker = good supervisor?
• No management training (or informal)
– Pass on bad habits
• Lack of time to train, coach, work with staff
Job Relations
• Let each worker know how they are doing
– What do you expect of the person?
– Point out ways to improve
• Give credit where credit is due
• Tell people in advance about changes
– Tell them why if possible
– Work with them to accept the change
• Make best use of each person’s ability
Hospitals Using TWI Today
• Children’s Medical Center Dallas
• Virginia Mason Medical Center
• Intermountain Healthcare
• ThedaCare
• Yuma Regional Medical Center
• Many unknown experiments
Yuma Regional Medical Center
• 333 licensed beds20,000 Admissions 65,000 ER visits
• Service lines– Open heart surgery
– Renal dialysis
– Multimodality cancer therapy
• Lean Six Sigma Culture– 1st pilot project – Laboratory
– 2nd pilot project now starting in ER
Lean Journey at YRMC
• Began in the clinical laboratory
• Spread to the histopathology lab
• Inspirational leadership from Chief of Pathology
• Results: pathology operations improved using Lean framework to integrate new technology
– Pathology information system – upgraded version
– Barcode-driven, voice-enabled workflow
– Improved TAT: 95% cases reported in 1 day
• A new issue was then driven to the forefront
The Histology Lab Problem
• Order Entry position:
– Six (6) people in 3 years
• Why such high turnover?
– (#1): “We just can’t seem to find/hire good people”
– (#2): “We are too tolerant of mistakes … … need more accountability”
• (Refined question) Why so many mistakes?
– (#3): “Job is too big … no one person can do it”
The Histology Lab Problem (cont.)
• New Histology supervisor (came up through the ranks) took collaborative approach
• (Refined) Why so many defects?– (#4): “We do not adequately train …
… new Order Entry staff.”
• Complete job content (“JBS”) had never been documented
The Histology Lab Problem (cont.)
• Initial documentation of job steps developed jointly by supervisor and histology lab staff.
• One-on-one training of new hire by supervisor using a 4-step JI-like process.
Initial Order Entry (JBS) Job Steps
• Verify requisition to specimen• Verify patient name• Verify insurance for O.P. cases• Verify specimen information/ name• Align specimens/triage (no like
specimens placed back to back)• Place decal gall stone jars• Verify primary physician & cc physicians• Distribute samples (fluid/tissue), fix w
cytolyte [to lab]; follow cyto-protocol• Verify & order additional histology
orders (ex. CD-8, special stains, IHC)• Create cytology slip if required• Organize paperwork for login• Verify D.O.S.• Verify spelling of specimen• Distribute Dr’s gross vs. Chuy’s gross• Verify ICD-9 bone marrows; Note BM
logged in by histo-techs• Verify at login for special studies orders,
done at reference labs ( RPMI, fetal chromosome, Oncotype, etc.)
Dr P Add Picture of list
Engaging All the Staff
• Other expert staff contribute knowledge of order entry job
• “What’s Bugging You?” Board
No Job is an “Island”
Daily and Weekly Lab Duties (all staff)
Order Entry Defects: Old Culture
Cases reviewed in December 2008Total cases reviewed = 673Total errors = 226Error rate = 33.5%
Incorrect data Cases % of Errors Omitted physicians 79 11.7% Incorrect specimen name 16 2.38% Incorrect/omitted acct. # 6 0.90% Incorrect patient name 13 1.93% Incorrect date of birth 2 0.30% Incorrect date of service 53 7.87% Incomplete/incorrect cytology 57 8.46%
***Data Gathering initiative Yuma Regional Medical Center, Kathleen Kardell, 12/08-present
Order Entry: New Training Culture
Cases reviewed in February 2009Total cases reviewed = 1526Total errors = 63Error rate = 4.13%
Incorrect data Cases % of errors
Omitted physicians 20 1.31%
Incorrect specimen name 21 1.37%
Incorrect/omitted acct. # 3 0.20%
Incorrect patient name 5 0.33%
Incorrect date of birth 1 0.06%
Incorrect date of service 6 0.39%
Incomplete/incorrect cytology 7 0.46%
88% improvement
Order Entry: New Training Culture
Cases reviewed in March 2009(Feb 25 – March 26, 2009)Total cases reviewed = 1496Total errors = 51Error rate = 3.41%
Incorrect data Cases % of Errors Omitted physicians 20 1.34Incorrect specimen name 11 0.74%Incorrect/omitted acct. # 1 0.07%Incorrect patient name 10 0.67%Incorrect date of birth 3 0.20%Incorrect date of service 5 0.33%Incomplete/incorrect cytology 1 0.07%
17% improvement
Order Entry: New Training Culture
Cases reviewed in April 2009(March 27 – April 27, 2009)Total cases reviewed = 1529Total defects = 40Defect rate = 2.62% 23% improvement
Incorrect data Cases % of Defects Omitted physicians 13 0.85 %Incorrect specimen name 19 1.24%Incorrect/omitted acct. # 0 0%Incorrect patient name 0 0%Incorrect date of birth 1 0.06 %Incorrect date of service 5 0.32%Incomplete/incorrect cytology 2 0.13%
Defect Reduction Results
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Dec '08 Feb '09 Mar '09 Apr '09
Defect Rate
Progress through 2009-2010
4.13
3.41
2.96
2.51
5.3
0.84
3.6
1.21
0.74
1.281.1
0.840.63
0.92
0.52
0
1
2
3
4
5
6
Perc
en
t
Months
Histo-Pathology - Accessioning Defect Rate
Series1
3% Target
Histopathology Lab Improvement System
The Pillars of Lean
Develop your
People
TWI In
Healthcare
RelentlessImprovement
AutonomationKaizen
(PDCA +)
Lean Methods and CultureFor
Histopathology Laboratory
Let My People Grow
• Building the Pillar of Participation:
– “Engage, train and develop Your People”
– Harness their unique contribution … … their “DNA” of participation
– “Everyone has a part to play”
Let My People Grow
• “Deep Respect” - Fujio Cho
– Go See (Gemba)
– Ask Why (Root-cause problem solving)
– Show Respect (Engage, train and develop)
It’s More Than Just ‘Training’
• Standardized work and Kaizen
• Foundation is well-trained, fully-engaged workforce
• Fully engaged Top Management …… leading the parade
Make People Before Making Slides
Contact Info
Mark Graban
• www.lean.org
• www.leanblog.org
• www.hcvln.org
• www.twitter.com/LeanBlog
Dr. Peter Patterson
• www.twitter.com/IDrPete
