Skip Stewart made new discoveries about standard work when he transferred to the healthcare industry to introduce Lean practice into Baptist Memorial Health Care, a network of 14 hospitals in the Memphis and surrounding area. It was there he was introduced to TWI and he quickly realized the power of good training practice in the healthcare field.
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Joe Dager: Welcome everyone. This is Joe Dager, the host of the Business901 Podcast. With me today is Skip Steward. He is the System Director of Performance Improvement at Baptist Memorial Healthcare in Memphis, Tennessee. Skip has a variety of accomplishments, qualifications and certifications in the quality improvement field way too many to even start with but few would be more important than his superior communication skills with all levels of personal and in a variety of industries. Skip, I’d like to welcome you, and one of those skills happens to be a certification in Training within Industry.
Skip Steward: Yes. Thank you so much. I’m glad to be here.
Joe Dager: You’ll be talking about transitioning from manufacturing to healthcare at the upcoming TWI Summit this May. Can you just briefly tell me about your talk?
Skip Steward: Basically, what I’m talking about is I have spent a majority of almost 24 years in my career. Majority of it was in manufacturing and even when I spent 4, 5 years in the private equity world, a lot of that was manufacturing, a lot of it was also getting exposed to healthcare. I’ve always been a big believer in the concept of standard work and it’s one of those things I’ve always wrestled with mentally and tried to think about how to improve it. Even though I heard about this concept called TWI, where I was ignorant was I was with the understanding that it was maybe delayed at the document or the information was laid out and how it was presented and that Toyota had their method and everyone else has their own method. I never gave it a lot of consideration and when I completely walked into healthcare, even though I got exposed to it in private equity for over 5 years when I got into the hospital setting mid-2013, I realized there was so much I didn’t know. I realized I had to be humble on a subject that I thought I knew much about and that’s when I was introduced to what is known as TWI or Training Within Industry by way of the TWI Institute and specifically working with Patrick Graupp.
Joe Dager: That’s what attracted you to TWI. What else made it special with you because you seem to really attach yourself to it?
Skip Steward: Sure, what has made me so attached to it and I am, I’m very much attached to it, I’m a big believer in it, is philosophically, intellectually, psychologically it goes along with almost everything I believe. I believe that I’m very much a believer in the concept of muscle memory. I wrestled in college in Arizona. I was a father of 2 children, still I’m a father of 2 children but and as I tried to teach them things I worked on the concept of muscle memory. I know that a lot of people talk about, hardwired, that word becomes very popular today but I’m under the belief system that unless it’s standard behavior it’s not standard work. All it really basically is intellectual knowledge typed up on a piece of paper.
The same way that we train people in all industries, healthcare, manufacturing, it is no way I would ever train my children. What we do in most industries is we do what I refer to as ‘death by PowerPoint’, give them a lot of information feed them with a fire hose. And then, we have them sign some form of a competency document. The problem with that is once we do that we’ve only got 2 choices in my mind. One choice is to say, “You know, John or Jane Doe, I’m really sorry that, ”we may make a mistake, of course, when they make a mistake the issue becomes either, A, “You know, John or Jane Doe, I didn’t do a good job of training you and so it’s on me.” We don’t rarely ever choose that choice. We normally choose B, the alternative choice of saying “There must be something wrong with you.” We get caught in the blame game, and we start looking for the root who instead of the root cause. It falls into my thought process that training really should be done one-on-one that it goes against the paradigm of some people because they think “How in the world could you actually get that done?” That’s the same thing that we had to deal with at Baptist. But, there’s an answer to that question.
Joe Dager: Well, that answer will hopefully come out in this podcast. But, where do you start? I’ve looked at your, you got a great handwritten diagram that I’ll share with the audience with your permission but where do we start with TWI? Do we start in the Job Instruction area or Job Method or where do we start?
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 “Yeah, there’re 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’re 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.
Joe Dager: You’re saying that Standard Work should be what I would say the result of Job Instruction and Job Training?
Skip Steward: Exactly, my argument always is it isn’t standard work until it’s standard behavior. If it’s words on a piece of paper, that’s wonderful, that’s great but until we have standard behavior to where numerous folks are all doing things in a very similar way, and they understand the ‘why’. That’s one of the big things about that breakdown is what you couldn’t see from that little cartoon is the 3 columns represent what’s known as the important steps, key points and the reasons why or another way of putting that is the ‘what’, the ‘how’ and the ‘why’. And, once people understand the ‘why’, it has a huge effect on them.
Joe Dager: That piece of Job Relations, the coaching and the learning dynamics, should that be studied along with Job Instruction when you’re introducing a TWI or should you have that Coach Trainer before you start trying to implement Job Instruction somewhere?
Skip Steward: Well, what I’ve been told by a lot of the people that, so first of all, yes. Job Relations is very, very important. I went to the Job Relations training. I’m not a certified Trainer in that, but it’s very important but where I’ve seen a lot of people has had a lot of success throughout the world doing is they always start with the Job Instructions first. Over time, they proceed to Job Relations but, like anything, you have to start somewhere. Most people that I’ve ever seen always start with Job Instruction, and then they transcend into, or they evolve into also adding Job Relations and then eventually Job Method.
Joe Dager: The Job Instruction, by looking at the diagram, it seems to me that it’s somewhat fluid in the beginning that you’re refining it as you go through the process and as you’re bringing individuals on into standard work. Would that be the right interpretation of the drawing?
Skip Steward: Yes, I mean the Job Instructions is when you layout the first important steps, you’re layering, you’re putting the first layer into the learner’s brain. You’re not trying to get them everything. You’re giving them the foundation or something I call the Anchor. So, you, for example, let’s say that the job has 5 important steps. You know, those are the 5 parameters that kind of outline the job. Step number 1, I walk into the room and introduce myself. Step number 2 is I assess the patient for pain. Step number 3, I offer toileting. Step number 4, I maybe look at the cleanliness of the rooms. Step number 5, I look at the safety of the bed and step number 6 I exit the room. Now, those are 6 steps but there’re a lot of details in each one of those steps but I don’t give the details yet until the second round. And then, on the third round, I’m going to give the reasons. But then, the learners going to come back, and I’m going to have them walk through it 4 times. So, now the learners going to actually experience show, tell and illustrate. They’re going to actually see the job being lived out, three times from me and then 4 times from them. That’s just on the very first initial training interaction. But if you think about it, it makes a lot of sense because most people tend to, their mind lives in stories and in pictures. What they don’t live in is PowerPoint bullet points. They can’t remember bullet point number 3 from the last PowerPoint presentation they saw. But, what they can remember is if you ask them a story, much of them remember a story, they can remember pictures. And so, what happens in that one-on-one training is they see a story in a picture lived out in their mind. We’ve had some great successes with the experiments that we’ve been running throughout our healthcare system. We have 15 hospitals, around 160 clinics over a 3-state range and so we just, we’re early on about a little over a year but just having some great success so far.
Joe Dager: I think the first resistance people would have from your description of it is ‘how do I train 3 hospitals and hundreds of people on a subject like that’. How does it work?
Skip Steward: Sure, great question. And you’re right, that is one of the very first objections to come up. One of the things that we’re doing right now is we experiment our way forward is myself or someone else will go into a hospital, and we’ll understand what they’re trying to accomplish. So, first let me give you an example. Let’s say in a Perioperative area we have some people that maybe understand in concept what TWI is all about or if not maybe they have to go through the training but if they go through the training, by day 3 they’re totally bought in. But, regardless, I’ll give one example. We went into a Perioperative area, and the Director of that area absolutely is bought into how TWI works, why it could be beneficial, how it can be a big help in laying down a solid foundation. She has, let’s say in the neighborhood of 90 people from the start of that values training to all the way through post-recovery. I went in, you only train 10 people at one time because they’re actually involved in doing something, 2 hours a day, every day, Monday through Friday, and it’s only 10 people. In that particular example, I went in there, had a class in the morning, a class in the afternoon and a class at night but when I left that week that Director had 30 people that were trained that could help train a job that we breakdown.
The math becomes real easy. In theory if there was a job that all 90 people needed to be trained in then, 90 divided by 30, everyone’s going to have 3 people at most to train. For example, Skip, if I was one of the Trainers, I would have Tom, Dick, and Harry to train and I’m going to train Tom, Dick, and Harry and I’m going to follow-up with Tom, Dick, and Harry every single time and it’s a tremendous amount of accountability because they know I’m coming back. If the Director sees that on that particular job, Tom, Dick, and Harry are not doing the job the way that the standard’s laid out, she can come back to Skip and say, “Hey, what’s going on?” That is one example of how it could be deployed, and you can deal with the whole ‘how do I deal with so many people’.
Joe Dager: I think what’s kind of funny with all due respect to TWI, but it sounds practically like a pyramid scheme.
Skip Steward: Oh, yeah. Well, I never thought about that. Yeah, I never thought about it that way but I do get what you’re saying.
Joe Dager: The same type of thinking that goes into TWI is that it’s not a matter of how many, it’s a matter of how well a little bit that someone gets trained because that’s how use actually multiplies is by having users. Not necessarily just training a bunch of people.
Skip Steward: Well, exactly, Joe and that’s one thing is when I’ve taught and I’ve trained hundreds and hundreds of people over the last year is, I don’t sleep a lot, but when I train people I can tell you the consistent comment that comes back from those people that will say “I’ve always known that what we were doing was not effective.” And, I said, “What do you mean by what you’re doing?” “Well, you know, the death by PowerPoint. I’ve known that it’s not effective.” They had a paradigm that they assumed there was no other alternative. What’s funny is when I ask them, would they ever train their child the way they train people at work, absolutely not, and that’s the same way we’d all answer. You know, my son’s a big baseball player but I never gave him a death by PowerPoint and say, “Okay, now son, I need you to sign this competency document so that if you can’t hit that curve ball at the plate, they all know it’s not your dad’s fault.”
Joe Dager: I think of this one-on-one, we live in this virtual world though, does some of these same principles apply?
Skip Steward: Well, you’re talking about across timelines as far as that. Is that what you mean?
Joe Dager: Well, the virtual world where we don’t have that one-on-one and I think of but in retrospect to what I just said, I think of the gaming industry and how kids learn on games is very much by doing and mentoring that their actual playing group games and learning from each other and getting instruction from them virtually. Some of these same principles to me carry on that learn by doing that immersion that they get in the games could very much be training online.
Skip Steward: Oh, yeah. Oh, yeah, sure. I mean, I think that, Patrick could probably speak a lot more to that because of his past 38, 39 years of experience doing this is much deeper than mine. But, I think I understand where you’re coming from. I think that makes sense. I’ll tell you the thing that has surprised some people is, we’ve had some success with a pretty large electronic records software. It’s probably the biggest one used in the country. But, what happened is just like most people but nurses definitely have a reputation for if they don’t understand the right way to do something, they’ll create a work around in a heartbeat. We’ve actually broken down jobs on the appropriate way to get in, I remember we were in an emergency room area, and someone didn’t know how to get into the software and do scanning. Patrick and I were together, and we broke the job down and polished it up and road tested it, as I would call it, and then we trained this super intelligent nurse gentleman named Donald and that was in November. I saw him in January and I said, “Donald, do you still have it? Do you still have that job?” He snapped his finger, and he said, “Muscle memory.” He said, “It’s all still there.” I said, “Oh, that’s great.” That’s a great story. There are a lot of jobs that can be broken down and taught and TWI is a sure and reliable way to train people to make sure that it’s truly, to us the cliché ‘Hardwired’.
Joe Dager: If someone was starting with Lean, would you encourage TWI as a first step or is TWI for a more mature Lean organization?
Skip Steward: Oh, no, no. I would absolutely recommend starting, I know that Jim Huntzinger and other people I don’t want to quote, I believe that they even said, you know, things like that something to the effect of “You could do TWI without Lean, but you can’t do lean without TWI.” Something to that effect is what I’ve heard Huntzinger say but I think it goes a lot along with what Taiichi Ohno from Toyota said where he talked about if there are no standards that it’s hard to improve off of that. So, yes, if you’re starting from ground zero I would actually say, “Seriously consider starting with TWI because if there are no standards, you’re going to improve off of what? How it’s done on first shift, second shift, third shift and so you’re going to start from where?” Yes, I would absolutely recommend starting with TWI.
Joe Dager: It seems like it’s a much better approach to the professionals to introduce Lean than some of the older Lean manufacturing terms of waste and flow, and those can be very useful thing but I would think TWI would be a much easier approach. Have you found that to be true or?
Skip Steward: Yes, I do. I have. I have found that people are especially once they see what it is, once they actually, even people that I have, we only have 10 participants, but I do have as many observers as I want and I’ll have executives and even, physicians sitting at the back and observe and normally, actually they didn’t take ‘til Wednesday, normally by Monday or Tuesday they’re like “Oh my goodness, this makes all the sense in the world.”
If you think about it, let me give you a great little story. A lot of times we tend to think that discipline professionals like nurses, phlebotomists, lab folks and even physicians that, well, they are professionals so it’s okay for everyone to do their own thing, but that’s really not the case. I know there’s one example where we broke a job down with blood cultures, actually polished it up. We practiced it on a nurse, and I can remember it like it was yesterday. The nurse said, “I’ve been a nurse for 25 years and until today I never knew that you were supposed to use the blue bottle first and then the purple bottle. I just always did what I was told to do.” Well, if all you ever do is what you’re told to do, that’s when people make mistakes, and that’s when errors occur. But, that’s not even the best part of that little story. I’ve told that story so many times in my travel in the last year and a half and I had so many nurses and physicians pull me aside and say “Hey, I’m not sure why you’re supposed to use the blue bottle first either.” I’ve even had physicians that don’t work for us when I told the story say to me “I didn’t think it really mattered.” Well, when we don’t know the why behind things, that’s where errors and mistakes and defects and even defects that maybe doesn’t harm anyone but can create waste and cost more money to be spent than necessary.
We just had some really great success. One thing I do want to say though because like many systems, I keep calling it a system because I think there’re 3 pieces that make up a TWI, the how to instruct 4-step method, the breakdown, and the training timetable that most people overlook. But, that system what I like to tell people about is the TWI system is nothing more than a counter measure. Ultimately, everything’s a hypothesis to get us from a current condition to a target condition. TWI becomes a great counter measure to get you from a current condition to a target condition. I say it that way because, unfortunately, Joe, as you know, many times people look at things like TWI or something else as a magic wand, and there are no such things as magic wands. It’s a counter measure. If you’re not getting from where you are to where your current condition to a target condition, I always ask people to check their hypothesis and their first question would be is “Are we even doing the TWI the right way?” The second question would be based on an additional countermeasure that you haven’t considered. I just wanted to point that out because I see a lot of times that people they’re looking for a magic wand and magic wands just don’t exist.
Joe Dager: One of the things that I’m not clear about in what you’re saying there is that someone’s going through this process, are they being trained in TWI alongside being trained in their actual job? Is that an important step, to get training actually about the process as it is or about the instruction of the process as it is about the process?
Skip Steward: The way that the training works is the 5 day, 2 hours each day training is they’re learning the skill set of how to instruct. In that workshop, they have to bring a task from their work into the class and we break the job down and then we grab a learner in the class and they have to instruct another person. They have to learn this new skill set of how to instruct. They teach someone in class then when the class is over we will break a job down, many times we already have a job for them to practice. We’ll break a job down and the majority of those people, we did 30 in a week like I gave you the example earlier and all 30 would practice that same exact breakdown with assigned individuals because one of the things we hear people say often, even after the training is this really is a learned skill. It’s not hard intellectually. It’s hard because there’s a level of awkwardness to it because it goes against what we do in our society.
They actually have to learn how to instruct in the class and then they take a very specific job like, you know, it could be drawing blood, it could be hourly rounding, it could be a whole slew of different kinds of things and they will actually train people on that specific job.
Joe Dager: Is there something that maybe I did not ask that you’d like to mention, Skip. You covered everything so well but is there something that sticks to your mind that you say, “Gee, Joe, should have asked that.”
Skip Steward: Well, there is one thing that gets overlooked, and it’s funny because I cover it on Wednesday, and you’ll almost see people’s eyes glaze over on it. Remember I told you there were 3 pieces. One was the how to instruct, we call it the blue card because it is blue, but how to instruct, it’s the 4-step method. Then, the second piece is the actual breakdown, the actual, form and the approach to breaking a job down and that’s normally where people stop. I would say the third piece is the actual timetable for training. In other words, that I think is so important because there’s a couple of different ways and especially with Microsoft Excel that it’s so easy to do. A lot of industries, healthcare included, I always ask them “How do you deal with life?” And, they’ll say, “What do you mean?” I’ll say, “Well, you know, people are going to be sick and not show up. Their kids are going to get sick. They’re going to have accidents. They’re going to; people are going to leave, and people are going to come. They’re going to have ice storms, so on and so on and so on. How do you think about life? How do you deal with that?” Never have I not gotten the answer, “Well, we just react to it.” And, I’ll say, “How’s reacting working for you?” So, one of the things I encourage people to do is make a training timetable, not only on a specific job but also maybe in their area of responsibility.
For example, what job in your area are causing defects because everyone’s doing things differently that’s contributing to defects and maybe it’s causing you pain because you only got these 2 people trained on a job, and if they’re not there that’s pretty painful. We try to get them to look at their area and at least lay out jobs not to go from, not to take a quantum leap but to evolve and have it to be a living document to where we’re thinking about what jobs are we going to ultimately breakdown to create standards, whether that be a job that’s causing them defects or whether that be a job because they need to create a deep bench. They need to create a cross train bench.
Another example, in healthcare, one of the things you see often is doctors only want to use certain nurses for certain tasks because they don’t feel like the other nurses that are standing in the room can do that task. Well, that’s where the training timetable can become, and TWI can become so helpful because then you can expand that army you created, what I call a deep bench.
Joe Dager: I think that is fantastic advice, so. What is upcoming for you and how could someone contact you?
Skip Steward: I’ll be speaking at the TWI Summit in May. By the way of LinkedIn or, you know, feel free to provide my Baptist e-mail if they want to e-mail me at skip.steward, that’s s-t-e-w-a-r-d, @bmhcc.org (skip.steward@bmhcc.org). That would be fine also, and I would love to help in any way we can.
Joe Dager: Well, I would like to thank you very much again, Skip. This podcast would be available in the Business901 iTunes store and the Business901 Blogsite. So, thanks again.
Skip Steward: Thank you.
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