Getting to Standard Work in Health Care

Using TWI to Create a Foundation for Quality Care

Patrick Graupp, Martha Purrier

• Publisher: Productivity Press
• Year: 2021
• Print ISBN: 9780367462673
• eBook ISBN: 9781000434033
• Topic: Medicine
• Subtopic: Leadership

Addressing the challenges involved in achieving standard work in health care, Getting to Standard Work in Health Care, 2nd Edition describes how to incorporate the Training Within Industry (TWI) methods of Job Instruction (JI), Job Relations (JR) and Job Methods (JM) to facilitate performance excellence and boost employee morale in a health care organization. It not only examines the TWI methodologies but also explains how this program is as vital and applicable in today's health care environment as it was when it was developed to train replacements of an industrial workforce off to fight in WWII.

Placing this methodology squarely within the health care paradigm, the book uses easy-to-understanding terminology to describe how these methods can make all the difference in the delivery of quality health care. Supplying the foundation for successful Lean practice in health care, it clearly defines the role of standard work and leadership skills in relation to Lean health care.

The updated text includes new case studies of current TWI usage in health care that demonstrates how to successfully roll out a sustainable TWI initiative. All new chapters on Job Relations and Job Methods give insight into the full scope of TWI skills development. Including examples of TWI application during the Covid pandemic, the book provides readers with the understanding of how to use these time-tested methodologies to improve training, increase engagement, and deliver continuous improvement in your organization.

II

Job Instruction Training

Chapter 5 Four Steps of Job Instruction

DOI: 10.4324/9781003035305-5

Introduction

We saw in the last chapter the vital need for good job instruction in hospitals and health care facilities. Training employees on job procedures, then, needs to be a regular task due to changing work demands, changes and improvements in procedures and standards, workforce turnover, the increasing need for cross-functional training, and the never-ending progress of medical practice and technology. At the very least, worker performance, regardless of whether people are new or experienced in their tasks, is not always where it needs to be. Moreover, we saw in Section I how proper training in standard methods, and ensuring that these standards are maintained on a consistent basis, created a baseline of standard work that is vital for continuous improvement to succeed. If health care facilities want to improve their performance and ensure the best possible patient care, they must start with a well-trained workforce.

Most organizations understand the need for good training and they provide a specified amount of time for this training, usually known as orientation. The orientation of a new worker in health care is often a shared responsibility involving the supervisor, a preceptor, and staff from a centralized education department. The supervisor has the final responsibility of evaluating the worker’s performance and competency. The preceptor is a skilled and experienced co-worker who instructs from the work unit and shares patient care assignments with the new worker, gradually increasing the independence and assignment workload of the learner. Side by side, the preceptor validates the new worker’s ability to perform the tasks associated with the assigned job. The third party contributing to orientation is the centralized education team, often called the Department of Clinical Education, or something similar. This team provides training for jobs that are shared among work units regardless of the specialty, for example, medication administration. In this case, all nurses will need to know how to operate the equipment associated with this job: medication dispensing machines, computerized charting, and the safety procedures incorporated into the process. Medications specific to certain patient populations (such as sedating drugs used to treat intubated patients) would be covered by the unit-based preceptor. The clinical education team is most likely to train in a classroom or in a skills lab away from the clinical work unit where the worker is assigned.

So the issue is not usually in providing orientation or training. What is being questioned here is the method of instructing. Is it viable, effective, and complete? Let’s look at two common, but insufficient, methods of instruction: Showing Alone and Telling Alone.

Showing Alone

It is a very common practice in health care facilities to instruct employees by showing them how to do a job. Showing a person how to do a job is a critical element of good instruction, but when used alone, can lead to very serious problems. Here’s a true story of how one preceptor failed to train a person properly when she simply showed the person how to do it:

The preceptor was teaching a new nurse how to attach an arterial line to connector tubing for the purpose of flushing the line. The job consisted of connecting the two tubes, one from the connector tubing and the other from the arterial line already attached to the patient’s arm. The job had to been done fairly quickly and efficiently or else blood would leak out or air and contaminants could enter the line, so the supervisor showed the new nurse how to do it several times. What the new nurse failed to notice, however, was how tightly the connection had to be twisted on. When he was allowed to do it himself, the new nurse did not twist the connection on tightly enough into the locking position. The two tubes quickly snapped apart and blood from the patient’s arm began draining the line, causing the patient to panic and the new nurse to scramble to correct the situation.

The failure to do the job correctly was not the new nurse’s fault. No matter how simple it may seem, a job cannot be mastered by observation alone. Seeing a job does not always translate into being able to do it. Many motions are hard to copy, and most learners usually miss the tricky points. Even if they can do the job, it is usually no more than a copy of the motions and doesn’t mean they understand the job. Yet, surprisingly, countless people today are simply being shown how to do their jobs with little more explanation than: “Do it like this.” This type of poor instruction leads to many of the problems we face in health care facilities.

Telling Alone

Another very common practice when giving instruction is telling a person how to do the job. As with showing, telling someone what to do is a critical element of good instruction but, when used alone, can result in serious problems. To demonstrate how this style of training can result in failure, imagine you are a new worker in a health care facility and someone simply tells you the correct way of washing your hands, without showing you how and with no gestures or motions. The dialogue might go something like this:

Turn on the faucet and wet your hands with water so that they are completely wet. Get soap from the dispenser making sure that you have enough to cover all of the surfaces including the backs of your hands and the fingers. Rub the palms of your two hands together back and forth and in a circular motion. Then rub the palm of one hand on the back of the other hand backward and forward and in a circular motion. Repeat for the other hand. Interlace the fingers of both hands, palm to palm, and move your palms back and forth so that the insides of the fingers rub against each other. Curl the fingers of your right hand into a fist and rub the backs of those fingers backward and forward on the palm of your left hand. Repeat with the fingers of your left hand in the right palm. Take the tips of the fingers of your right hand and rotationally rub them backward and forward on the palm of your left hand. Repeat with the fingers of your left hand in the right palm. Take the thumb of your left hand and grasp it with the palm and fingers of your right hand rotationally rubbing the thumb in the palm of the hand. Repeat with the right thumb in the palm of your left hand. Rinse your hands thoroughly until all the soap is removed, being careful not to touch the faucet or the sink. Leave the water running. Dry hands thoroughly with a single-use towel and use the towel to turn off the faucet.

Would you be able to perform the task completely and exactly as specified just hearing this explanation? Things seem complicated when you are listening to words and most people don’t “get it” simply by being told how to do something. Many movements, however simple, are difficult to describe in words and few of us can use the exact words or the right number of words to explain a procedure correctly and completely. When a person hears a long explanation, their minds do not piece it together in the same logical order in which it was described. The brain can only absorb so much information at one time, so details get mixed up and the person focuses on certain points while neglecting others.

Over time, with enough telling and enough showing, a capable person will be able to do the job. Through the process of trial and error, they may even learn all the nuances or tricks to doing the job. But this approach is not effective or efficient and contributes to mistakes, injuries, and delays while the job is being mastered. What is more, as each person “learns” the job at his or her own pace, the prescribed method will be “learned” differently by each person doing it. Depending on what troubles or difficulties they encounter, they will devise different means of accomplishing the task. The result is that we do not end up with standard performance that each person doing the job performs consistently each time they do it.

A Sure and Effective Method of Instruction

If we are to truly attain a standard method of doing our jobs, a better way of instruction is required. The Job Instruction (JI) four-step method fits this bill and, when used properly, can assure a successful training experience each time it is applied. This method works quickly and efficiently while ensuring that the learner remembers how to do a job correctly, safely, and conscientiously. The method is based on fundamental principles of human learning that are timeless and always true, a fact confirmed by supervisors who were formerly K-12 teachers and have noted that the JI method incorporates the fundamentals they were taught in their teacher education. Professional trainers as well have pointed out how the JI method covers all three styles of adult learning: auditory, visual, and kinesthetic.

Let’s look at the JI method first by reviewing the dialogue an instructor has with a person learning a job. We’ll assume this is a new employee without much experience working in a health care facility. One of the most important things he will need to do throughout each day of his work is to wash his hands properly so that he can protect both himself and patients by not contaminating them with harmful viruses or bacteria they might pick up from other sick patients with whom they come into contact. Of course, the employee being trained will both hear and see the instructor’s words and actions, so refer to the diagrams and notes that accompany the dialogue and try to imagine the activity taking place.

Pay attention to both what the instructor says and does as well as the order in which these things are performed. After reviewing the dialogue, we will look in detail at each item the instructor did in order to teach the job of hand hygiene using the Job Instruction four-step method.

Teaching Hand Hygiene

Instructor: Hello, Bill. How are you?

Learner: Fine, thank you.

Instructor: My name is Sarah Jones and I’m the supervisor on this floor of the hospital. It’s nice to meet you. This is your first week in orientation, isn’t it?

Learner: Yes, as a matter of fact, this is my second day.

Instructor: Well, are you getting along OK?

Learner: I’m really glad to be here although there is a lot to know.

Instructor: It takes some time to get used to a new place. But, if you need anything at all, please let me know. Today I’d like to teach you how to wash your hands properly. Now, I’m sure you’ve washed your hands before.

Learner: Of course.

Instructor: But here in the hospital it’s more than just washing your hands. You have to clean them thoroughly to be sure all the germs are killed. Have you ever had a shot and the nurse scrubbed your arm with alcohol where she was going to stick you? Why did she do that?

Learner: Well, if there are ...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• Foreword to Second Edition
• Foreword to First Edition
• Preface
• Acknowledgments
• About the Authors
• SECTION I CASE FOR STANDARD WORK IN HEALTH CARE
• SECTION II JOB INSTRUCTION TRAINING
• SECTION III JOB RELATIONS TRAINING
• SECTION IV IMPLEMENTING TWI INTO THE CULTURE
• Conclusion: A Call to Action
• Index