“TWI is essentially standard work for training. It helps you train everyone exactly the same way for a particular job.”
- Laurel Brown
What can Rosie the Riveter and her experiences during World War II teach us about improving the quality and safety of health care today? As surprising as it may seem, Rosie actually has quite a lot to teach us.
The technique that was used during the war to train Rosie – to turn her from novice to an experienced, exacting worker – is helping teams at Virginia Mason significantly improve their ability to achieve the highest levels of standard work.
Training Within Industry (TWI) was used extensively throughout World War II to train inexperienced workers quickly with superior efficiency. TWI was “designed specifically to quickly train industrial supervisors to quickly train neophyte workers … to do the jobs of the workers pressed into service in the armed forces,” observed Steven M. Grossman, Director of the TWI Institute. “In the factories in which warships and planes were produced, supervisors used the techniques taught by TWI trainers to geometrically increase the numbers of workers able to do standard work, thereby maintaining the high levels of production and quality critical to the war effort.”
The application in health care is particularly powerful for the countless repetitive processes that happen hundreds of thousands of times a week within a provider organization.
Sarah Patterson, Virginia Mason’s executive vice president and chief operating officer, said health care organizations typically hire new team members, put them in their job and basically tell them to watch others.
“It can not only be frustrating for new staff members, but it can also be a pretty scary experience for new people,” Sarah said. “It’s not a very respectful way to treat them.”
Sarah noted that it’s critical to ensure new hires have a job that is “doable,” but then “we need to support them, and provide training and resources to ensure they have what they need to do the job well.”
In pursuit of the perfect patient experience – a defect-free patient experience – VM leaders see TWI as a powerful training tool. Its effectiveness comes from the one-on-one nature of the training where an experienced teacher walks a new or existing employee through the essential steps involved in a process.
For example, at Virginia Mason, Roger Woolf, director, Pharmacy, and Laurel Brown, manager, Inpatient Pharmacy, led an effort using TWI to train technicians on new standard worked related to the preparation of intravenous medications.
“IV medication preparation happens hundreds of times a day at VM,” says Laurel. “And TWI is perfect for this because teaching standard work effectively is what TWI is all about. TWI is essentially standard work for training. It helps you train everyone exactly the same way for a particular job, such as the IV prep work we did.”
Virginia Mason’s Martha Purrier, RN, MN, is a leading authority on TWI and co-author (with Patrick Graupp) of a book called Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care. (For an excerpt, click here.) Martha says that TWI requires a very specific, prescribed series of steps:
How to get ready to instruct.
- Make a timetable for training − decide who needs training for what and by when.
- Break down the job − list the important steps, the key points and the reasons for the key points (this is what Laurel was describing).
- Get everything ready − round up equipment, tools, materials need to instruct.
- Arrange the worksite − neatly, as in actual work conditions.
How to Instruct
Step I – Prepare the worker
- Put the person at ease
- State the job
- Find out what they know
- Get the person interested in learning the job
- Place the person in the correct position
Step 2 – Present the Operation
- Tell, show and illustrate one important step at a time
- Do it again stressing key points
- Do it again stressing reasons for key points
Step 3 – Try out performance
- Have the person do the job − correct errors
- Have the person explain each important step to you as they do the job again
- Have the person explain each key point to you as they do the job again
- Have the person explain reasons for key points to you as they do the job again
Step 4 – Follow up
- Put the person on their own
- Designate who the person goes to for help
- Check on the person frequently
- Encourage questions
- Taper off extra coaching and close follow-up
With the IV prep project – as with all other TWI projects – the trainer starts by preparing a job breakdown – dividing the IV prep process into a series of steps. She then gathers the appropriate materials and equipment she will need to instruct the worker.
“The TWI trainer walks the employee through new standard work at least three times, and each time the trainer layers in new information so the employee doesn’t experience information overload,” says Laurel. “And every person learns the job the same way.
“The trainer then does it again with the tech, but this time the trainer goes into deeper detail with each step. A key point about the label is to only work with one label at a time. The key point with supplies is to only collect supplies for one patient at a time.”
And the third time through the trainer explains why each step is necessary and the explanation of the work – the rationale for why it is so exacting – enables the employee to have a broader understanding of the rationale for the work.
“A big aha! for us is that with a lot of standard work you fail to tell the why,” says Roger. “But when we do, it gives the staff member a much better understanding, a greater depth of understanding.”
Roger, Laurel and their colleagues at VM have found TWI helps reduce the amount of time staff members take to learn their jobs well and the technique has applied successfully in areas such as high-risk medication checks, patient rounding and hand washing.
VM long ago learned that significant gains tend to backslide over time. That is why VM teams are so diligent about following up on work in a sustained manner. With TWI, Roger and Laurel do not assume once the tech is trained he will always do the work perfectly. They have built in ongoing support and encouragement and made it clear there is a specific person he can go to for help at any time with any concern or question. This safety valve for the employee is immensely important in providing a sense of confidence and comfort for the worker.
“Applying TWI can sound simple, but one of the things we’ve learned is that breaking down each task is critical to its success, and that can be some of the hardest work to do,” Sarah said. “And it can’t be a top-down activity. We need to ensure teachers and trainers are embedded throughout the workforce.
“We’ve made great strides at VM, but we have a lot more work to do.”