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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

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