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The Continuum of TWI Development

From Knowledge to Skill to Mastery

Scott Curtis and Patrick Graupp

The Continuum Model

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Five needs of good supervisors

Work

ResponsibilitiesKNOWLEDG

E

SKILL

Instructing

ImprovingMethods

Leading

Safety

HOW TO INSTRUCT

Step 1 – PREPARE THE WORKER

§ Put the person at ease

§ State the job

§ Find out what the person already knows

§ 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 stating reasons for Key Points

Instruct clearly, completely and patiently, but don’t give

them more information than they can master at one time

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

Pointsto you as they do the job again

Make sure the person understands

Continue until youknow they

know

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

IF THE WORKER HASN’T LEARNED,

THE INSTRUCTOR HASN’T TAUGHT

HOW TO HANDLE A PROBLEMDETERMINE OBJECTIVE

STEP 1 – GET THE FACTS§ Review the record§ Find out what rules and customs apply

§ Talk with individuals concerned

§ Get opinions and feelingsBe sure you have the whole story

STEP 2 – WEIGH AND DECIDE

§ Fit the facts together§ Consider their bearings on each other

§ What possible actions are there?

§ Check practices and policies

§ Consider objective and effect on individual, group

and productionDon’t jump to conclusions

STEP 3 – TAKE ACTION§ Are you going to handle this yourself?

§ Do you need help in handling?

§ Should you refer this to your supervisor?

§ Watch the timing of your action

Don’t pass the buckSTEP 4 – CHECK RESULTS§ How soon will you follow up?

§ How often will you need to check?

§ Watch for changes in output, attitudes, and

relationshipsDid your action help production?DID YOU ACCOMPLISH YOUR OBJECTIVE?

HOW TO IMPROVE

JOB METHODS

A practical plan to help you produce greater

quantities of quality products in less time by

making the best use of the Manpower, Machines

and Materials now available.

STEP 1 – BREAK DOWN THE JOB

1. List all details of the job exactly as done in the

Current Method.

2. Be sure details include everything:

§ Material Handling

§ Machine Work

§ Hand Work

STEP 2 – QUESTION EVERY DETAIL

1. Use these types of questions:

WHY is it necessary?

WHAT is its purpose?

WHERE should it be done?

WHEN should it be done?

WHO is best qualified to do it?

HOW is the ‘best way’ to do it?

2. Question the following at the same time:

Materials, Machines, Equipment, Tools, Product

Design, Workplace Layout, Movement, Safety,

Housekeeping

www.TWI-Institute.org006Rev05

Three courses for three skills

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Skill in Instructing Job Instruction

Training

Skill in Leading Job Relations

TrainingSkill in

Improving Methods Job Methods

Training

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The Continuum Model – Foundational/Advancing Knowledge

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Foundational Knowledge

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Which one of the 5 elements following IS NOT common in all the TWI training programs?

A. 4-Step Method. B. 10-hour training courses, 2 hours per day for 5 days. C. Max 10 persons per class. D. An exam or test at the end of the training. E. Learn by doing approach (application of methods on

real jobs).

• Articles• Webinars• Knowledge

Certification

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Books

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The TWI Workbook: Essential Skills

for Supervisors (Second Edition)Productivity Press, Shingo Prize 2015

Patrick Graupp and Robert J. Wrona

2007 Shingo Prize Winner

Implementing TWI: Creating and

Managing a Skills Based CultureCRC Press, October 2010

Patrick Graupp and Robert J. Wrona

Building a Global Learning

Organization: Using TWI to Succeed

with Strategic Workforce Expansion in the LEGO GroupCRC Press, June 2014

Patrick Graupp, Gitte Jakobsen & John Vellema

2015 Shingo Prize Winner

Advancing Knowledge

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• Summits• Ongoing practice,

deployment• Network development

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Securing and Maintaining Top Management Support

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• Understand the need for TWI• Select a strong TWI Champion to drive

change• Designate a member to report progress

to management• Openly support the TWI initiative

Set up management introductory seminars to:

Use TWI knowledge to drive interest and commitment

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Gallup’s Employee Engagement Survey1. I know what is expected of me at work.2. I have the materials and equipment I need to do my work

right.3. At work, I have the opportunity to do what I do best

every day.4. In the last seven days, I have received recognition or

praise for doing good work.5. My supervisor, or someone at work, seems to care about

me as a person.6. There is someone at work who encourages my

development.

JI JR

JI JM

JI JR JM

JR

JR

JI JR JM

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Use TWI knowledge to drive interest and commitment

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7. At work, my opinions seem to count.8. The mission or purpose of my company makes

me feel my job is important.9. My associates or fellow employees are

committed to doing quality work.10. I have a best friend at work.11. In the last six months, someone at work has

talked to me about my progress.12. This last year, I have had opportunities at work to

learn and grow.

JR JM

JI JR JM

JI JM

JR

JI JR

JI JR JM

The Continuum Model – Skill

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Skill development – Standardized Delivery

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• Each method is stated in shop terms directed at “supervisors” who are “anyone in charge of people or who direct the work of others”

• Scheduling of five 2-hour meetings to keep the subject fresh and not keep people away from their jobs over long periods of time

• Small groups of 10 people• Each participant demonstrates

in class that they know how touse the method

The Continuum Model – Coaching

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The World Standard Guide for Hand Hygiene

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Job Breakdown BEFORE 10-hour Class

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JOB BREAKDOWN SHEET DATE: January 21, 2008 TEAM LEADER: Donna S., Gillain A., Joan C. SPONSOR: Donna S., MD AREA: All areas providing direct pt care or in contact with pt care supplies, equipment or food

JOB: Hand Hygiene in compliance with CDC & WHO hand hygiene guidelines

WRITTEN BY: Joan C.

MAJOR STEPS KEY POINTS REASONS FOR KEY POINTS Step #1: Identify the need for clean hands

Remove artificial fingernails or extenders when in direct contact with pts or their environment

Artificial nails house germs that can be passed on when you touch pts

Clean hands whether or not you use gloves (i.e. before putting on gloves & after removing gloves)

Gloves are not a substitute for cleaning hands because gloves don't completely prevent germ transmission

Before direct contact with pt, pt's environment or equipment

Protect the pt against harmful germs carried on your hands

After direct contact with pt, pt's environment or equipment

Protect yourself & the health-care environment from harmful pt germs

Step #2: Inspect your hands to determine best cleaning method

If not visibly soiled, use alcohol-based gel Cleaning with gel is faster, more effective, and better tolerated by your hands

Visibly soiled hands or hand with fecal contamination require washing with soap & water

Dirt, blood, feces or other body fluids are best removed with soap & water (C. diff spores are not killed with alcohol-based gel)

Step #3: Use enough product to cover all hand surfaces & fingers

GEL: Cover all surfaces with a thumb nail-sized amount

Friction & skin contact are required to remove germs

WASH: Wet hands with water, wash with enough soap to cover all hand/finger surfaces

Step #4: Spend enough time cleaning your hands

GEL: Vigorously rub until product dries on your hands

Antiseptic action is not complete until fully dried (approx 15 sec.)

WASH: A minimum of 15 sec. (the length of singing "Happy Birthday to You")

As least 15 sec. is needed to ensure complete coverage of hand surfaces

Use paper towel to turn off water faucet

Prevent transfer of germs from faucet onto clean hands

Step #5: Let your hands completely dry

Moisturize hands with lotion available through Central Supply

To minimize contact dermatitis without interfering with antimicrobial action

Put on gloves after hands are dry Skin irritation may occur if moist hands come in contact with glove material

Step #6: Perform task with clean hands

Task is done immediately after cleaning hands You may be distracted & touch unclean surface with clean hands

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Breakdown Sheet AFTER 10-hour Class

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IMPORTANT STEPS KEY POINTS REASONS

A logical segment of the operation when something happens to advance the work.

Anything in a step that might—1. Make or break the job2. Injure the worker3. Make the work easier to do, i.e. “knack”,

“trick”, special timing, bit of special information

Reasons for the key points

1.Wet hands Without soap Soap rinses away

2. Apply soap Cover all surfaces Kill all germs

3. Rub hands 1. Palm to palm2. Palm to backs

1. Clean entire surface2. Clean entire surface

4. Run fingers

1. Thumbs 2. Interlocking3. Backs of fingers to palm4. Tips of fingers to palm

1. Most active part of hands2. Sides of fingers cleaned at one time3. Cuticles and knuckles4. Under finger nails

5. Rinse hands Leave water on Prevent recontamination of hands

6. Dry Use towel to turn off water 1.Prevent recontamination of hands

Coaching JIB Skill with “Deep Dives”

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Group Development of JIB

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No. 1_

JOB INSTRUCTION BREAKDOWN SHEET - HEALTHCARE Task: Central Line and PICC Dressing Change________________________________

Supplies: Clean gloves, dressing kit, CHG dressing, sterile saline syringes

Equipment & Materials: Trash can, bedside table • AIDET/HAND HYGIENE (HH)

______________________________________________ IMPORTANT

STEPS KEY POINTS REASONS

A logical segment of the operation when something happens to advance the work.

Anything in a step that might – 1. Make or break the job 2. Injure the worker 3. Make the work easier to do, i.e.

“knack”, “trick’, special timing, bit of special information

Reasons for key points

1. Prepare room & patient

1. Prepare table and patient 2. In bed on back 3. Elevate bed 4. Masks 5. HH before gloves

1. Safety and decrease risk of infection

2. More stability, avoid line displacement

3. Good body mechanics 4. & 5. Decrease risk of

infection 2. Remove and inspect

site 1. Slowly toward insertion site 2. Squirt saline on CHG gel-don’t

touch 3. Assess for infection 4. Look & feel

1. Avoid line displacement 2. Loosens gel to come off

more easily, skin integrity 3. Decrease risk of infection 4. Identify and treat

infection

3. Clean with alcohol 1. HH/don sterile gloves 2. No alcohol on the PICC

catheter. 3. From insertion site outwards 4. 3 sticks to 3 inches 5. Air dry

1. Decrease risk of infection 2. Prevent breakdown of

PICC catheter. 3. Clean contaminants

away from insertion site 4. Removes biofilm 5. Dry time is kill time

4. Disinfect w/CHG

1. If prevantics-flat side to skin/both sides, if chloraprep-squeeze wings

2. Back & forth to 3” from site 3. Air Dry 30 sec

1. Correct Chg. Distribution, decrease risk of infection

2. Clean both sides of the epithelial cells

3. Dry time is kill time 5. Apply new dressing

1. Holding by handles 2. Gel pad over site 3. Notch over tubing 4. Smooth surface to edges 5. Change hep-locks with green

caps

1. Prevents contamination of dressing

2. Provides continuous antimicrobial action

3. Seals dressing 4. Avoid air bubbles or

wrinkles 5. Decrease infection risk

6. Label dressing 1. Remove PPE/HH 2. Date/time dressing 3. Lower bed 4. Document in EMR

1. & 2. Decrease risk of infection

2. Communicates with Care team

3 Patient Safety 4. Communicates with Care

team

8-Week Follow-up with Job Relations

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1-hour weekly meetings to:• Review current, on-going people

problems using JR 4-Step Method• Proactively plan use of Foundations for

Good Relations using planner• Identify potential problems and

preventative measures• Mark progress of changing relationships

over the 8-week period

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Organize a Pilot Project

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Assign Responsibility

Provide Adequate Coverage

Provide Coaching

Publicize Results

Give Credit When Due

Train the Trainer

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Internalize TWI training to move TWI forwardPull the TWI training throughout the workforceProvide JIB follow-up trainingAudit the training processProvide ongoing coaching to sustain use of the new method

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The Continuum Model – Mastery

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Feedback from “Masters Meetup” Yesterday

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What our TWI “Masters” said about TWI Mastery:

• In the development of the ideal TWI Master in your organization, what attributes / behaviors / knowledge / skills would you think they should have?• What “top management support” might such a “TWI Master”

require to fully deliver on their potential?• What type of work environment / culture might need to be in

place for such a “TWI Master” to fully deliver on their potential?

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Connecting the Dots Between TWI and Kata

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PDCA Cycles

ChallengeNext

TargetCondition

CurrentCondition

Obstacles

Stability

Productivity

Environment

TWI - Job Instruction

TWI - Job Methods

TWI - Job Relations

Problem Solving with the TWI Skills

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Problem Points guide us to what skill to use to solve the problem:

• Mechanical/Physical Problems—use JM to solve• People Problems:

– Don’t know/ Can’t do—use JI to solve– Don’t care/ Won’t do—use JR to solve

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Using TWI to Solve People Problems

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Don’t KnowCan’t Do

Don’t CareWon’t Do

Faulty InstructionWrong Assignment

Personality Situation

Insufficient InstructionIncorrect InstructionInefficient Instruction

No Instruction

Little or no preparation of:Instructor

Work PlaceLearner

{

} }JR JI

Basic Cynefin Framework

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Unpredictable Outcomes Repeatable Outcomes

COMPLEX‘Unknown Unknowns’

Realm of innovative and creative counter-

measures

COMPLICATED‘Known Unknowns’

Realm of experts and analysis to find best

solutions

SIMPLE‘Known Knowns’Realm of rules &

regulations, standard work and best practices

CHAOTICCause and Effect

Are UnclearRealm of action and

rapid response

DISORDERMultiple

Perspectives

By Dave Snowden

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Cynefin Framework with TWI/Kata Application

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By John Bicheno

Unpredictable Outcomes Repeatable Outcomes

COMPLEX‘Unknown Unknowns’

COMPLICATED‘Known Unknowns’

SIMPLE‘Known Knowns’

CHAOTICCause and Effect

Are Unclear

DISORDERMultiple

Perspectives

TWI

KATA

Assessment of TWI in the Culture

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• The degree to which the TWI skills are evident in the behavior of every employee

• The frequency, duration, intensity and scope of the desired behaviors

• The degree to which leaders align the skills to drive ideal behaviors at all levels

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Assessors Interview People at All Levels

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• Top leadership• Line management• Front-line employees

…asking questions that are• Open ended and do not elicit simple ‘yes’ and ‘no’ answers• Bring out thoughtful responses• “Show me your thinking”• Explain both the How and the Why of their engagement with

the methods

Examples of Questions for Leaders

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What does TWI mean to this organization? What would you say is TWI’s role in promoting the principles to which the organization aspires?

Describe how the organization validates Job Instruction trainers to ensure they are teaching jobs properly using the JI 4-step method? What happens if they are not?

How do you follow up and observe managers and supervisors routinely using and applying good Job Relations skills with their employees? Describe your process for coaching them if they struggle with Job Relations?

Describe your organization’s thinking on continuous improvement. How can or will Job Methods assist in creating a culture of improvement in your organization?

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Examples of Questions for Managers

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Describe the utilization of the TWI methods and how they are applied on a regular (daily)

basis? How does their application help you achieve your managerial responsibilities?

Please describe a situation when Job Instruction was used as a remedy for handling a

performance problem? What were the results?

Describe the effect of having a consistent method of leadership using Job Relations across

all departments of the organization? How does that help you achieve goals in your own

department?

Can you show me a Current and Proposed breakdown sheet for Job Methods and describe

how you got to the improvement proposal? Explain how the improvement was

implemented and what were the results.

Examples of Questions for Associates

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What value does TWI provide you in your day to day activities? Please show me an example.

Have you ever been taught to perform a task or function by a TWI trainer using the Job Instruction method? If so, please describe the process and what it meant to you.

Describe any changes you have noticed in how your supervisor deals with you since the advent of the Job Relations training at your organization? Do you see your relationship with your supervisor improving? In what way?

Please give examples of how your manager or supervisor regularly asks for your ideas on how to improve Job Methods in your department? How has this changed your view of your job and the organization and how it works?

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Written Report Highlighting Strength & Opportunities

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• Should highlight guiding “True North” principles• Not a “test” – no scores or prizes• Should be a motivating learning experience for people• Positive and upbeat, not to take people down• Give a good sense of where they are in their development and

where they need to go• Highlight how these efforts are helping and contributing to the

organization• Should be a catalyst for people to recommit to the skills

Example of Written Report

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STRENGTHS• The extensive use of JR principles from top management coaching to onboarding displays an active use

of Seek Perfection. While we will never be perfect as people, the vision of consistent application of JR principles at all levels is admirable.

• Initial steps at JM prove that Embrace Scientific Thinking has effective application in a healthcare context.

OPPORTUNITIES• As you gain experience using JM you can use it more extensively in order to Focus on Process by

connecting JM activities to strategic initiatives and using it more proactively in Kata and Idea Generation activities.

• In order to Assure Quality at the Source, you can be more tenacious about using JI to attacking poor quality when you see it, like with the pump training. Don’t stop with just one success but replicate it across a wider area. One idea that came up was to choose what jobs you want a group of trainers to train before you send them to the JI training.

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Thank you

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QUESTIONS