As a System Director of Performance Improvement at Baptist Memorial Hospital, Skip Steward (a TWI Job Instruction Certified Trainer), drew this handwritten that shows his thoughts and process about using the Job Instruction method of Training Within Industry. Skip will also be presenting at the upcoming Training Within Industry Summit this May in Jacksonville, Fl.
Related Podcast and entire Transcription: The Tao of Training Within Industry
Below is Skip’s Description of his Diagram: 
Skip Steward: Under the umbrella of TWI, of course, you have Job Instruction, Job Method, and Job Relations. I believe there’s another one on Safety but we specifically started with Job Instruction. What’s interesting is that little cartoon, you can tell I call it, I baptized it because behind each character is part of our Baptist logo and that in the far left corner of that little cartoon that I drew up is a person sitting at a desk behind the computer. Unfortunately most of the time, that is where people start with some form of standard work, away from what we call the Gemba the actual place where the actual value is created, away from the Gemba, good intentions, good people but that’s where they start. The product of that effort will be normally something like a standard operating procedure.
My argument and that’s why I drew this little cartoon is that’s not where we should start with, maybe that’s perhaps where we should finish. As you move to the right of that little diagram, there’s a Job Instruction, that’s the area that we focus on at Baptist and with the Job Instruction breakdown. In my mind there’re 3 pieces to TWI when it comes to Job Instructions. One is the breakdown; one is the 4-step how to instruct card and then a third piece is, especially in healthcare I see people overlook, is the training timetable. They always focus on one piece but in my mind all 3 of those tools make up the TWI JI system. It’s both the breakdown, the how to instruct 4-step card and the training timetable.
We first start by going to where the actual work is and we actually breakdown the job. It’s almost like breaking it down in a skeleton, trying to understand exactly how this job should be done. Every single time that we have done that over the last year and a half in all of the experiments we’ve been doing. I call them experiments. I don’t refer to them as implementation. I think that would be flaw thinking. But, in our experiment, every single time we break these jobs down whether it be drawing blood or taking blood cultures or getting into a complex computer system program or doing hourly rounding or washing your hands or any of the jobs I could keep on talking about, every single time we find a tremendous amount of variation from nurse to nurse to nurse or any other discipline and that variation allows errors and mistakes to occur.
Once we go through the breakdown, and it’s not about the form. It’s about the thinking behind the form. I have many people, many consultants go on a copy of the Job Instruction breakdown form, and I see many consultants use them in the wrong way but it has nothing to do with the form, it’s the thinking behind the form. But, once we apply that thinking and use the form to break it down and polish it up, there’s a lot that goes into that. We then, we actually go out and train someone for the very first-time one-on-one. There are even times when that first-time things will come up.
You’ll notice that in the little diagram the arrow is shaped like a road because that’s the term we use, we call, we took that from Patrick Graupp, we called it Road Testing it. Let’s go Road Test it. So, we’ll Road Test it even before we train our initial person. We want to make sure all the bugs are worked out, that it’s polished up. But, on the first initial training effort, what normally takes the longest and we’ll do some training then we’ll have a follow-up session and you’ll notice that there happens to be in this diagram 5 follow-up sessions. We took that from, as a random arbitrary number that we took from Virginia Mason. They use that number. They wrote a book with Patrick called Getting to Standard Work in Healthcare. I think most people in healthcare know some of the great work that Virginia Mason’s done out in Seattle. But, we road tested and you’ll notice that the very first follow-ups have questions. Well, those who have questions both from the instructor and the learner but sometimes they’re questions that end up making you revise your breakdown to the next revision.
Every breakdown that I’ve ever been involved with over the last year and a half of experimenting, we normally run the second, third, fourth or fifth revision by the time we actually start training one-on-one. Then, we follow-up again. Once again, there could end up being more adjustments needed. Then, we have to follow-up again. What we chose to do is a weekly follow-up, whatever people are assigned to me, I am attached to those people, and those are my responsibility. But, sometimes when we follow-up we’ll find that maybe someone’s reverting back, and so we have to explain what the standard is again. Then, we’ll follow-up again, and we may discover some more improvement and hopefully eventually you’ll see on the very last follow-up we’ve got a stabilized, process what’s going on. At the very end then if you want to create an intellectual document known as a Standard Operating Procedure or something, I would say that that’s a place that could be helpful. I would say a SOP, or whatever you want to call it. It could be helpful, it shouldn’t be, and it shouldn’t be your main focus. Instead of starting there, I would say that we should end there.
What you see right in the middle of that little diagram is an iterative process of plan, do, study, act because if you think about it. If you just look at this diagram and think about how it works, it’s inherently built into it. It’s built into the actual process. It’s all based upon that assumption is the worker hasn’t learned, the instructor hasn’t taught, which is quite interesting because I actually pointed out at the beginning of the conversation, I’m a certified JI instructor, and normally people are very polite, and they won’t challenge that motto if a worker hasn’t learned, the instructor hasn’t taught until about Wednesday. The class is Monday through Friday, 2 hours each day. It’s not real intrusive. But, normally that Wednesday, someone will finally push back, and they’re polite on the first couple of days and they push back is always the same. It’ll be something like to the effect of “Well, aren’t there certain people that you just can’t train? Aren’t there certain people that have a bad attitude?” or something of that nature. My experience over 24, almost 24 years has been “There are different types of people and there’s always could be someone like that but I rarely ever seen someone that couldn’t be trained.”
I can relate to that because one of the things that most people won’t realize is I’m dyslexic and what most people don’t realize about dyslexia is it’s a language processing issue, and there’s always different forms of dyslexia. But, that’s how it helped me have a much better appreciation for not labeling people as, well, they’re just slow or that one just catches on a little quick. The ones that we say that catching on real quick are actually what my experience has been is many times they’re faking it.
TWI has been just a wonderful discovery for me and I’m still learning by any stretch of imagination but I learned a lot from the TWI Institute and friend Patrick Graupp on just the real skill set of breaking a job down and you layer it back into the learner’s mind because a learner can’t handle the feeding with a fire hose. They have to have it layered back into the mind. It goes along with my high school and college wrestling training. It goes along with the concept I also believe in what’s known as Toyota Kata. It goes along with a lot of just common sense. There are so many books out there, whether it be the 2009 book of known as the Talent Code or books about habits or anything else that talks about how to learn, how people learn. TWI, I think, has been out there for so long, and people are writing books today about something that’s been out there for decades.
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