In a recent opinion piece in the New York Times entitled, The Business of Health Care Depends on Exploiting Doctors and Nurses1, a grim picture of health care is painted; one in which, health care administration fails to create systems that remove burdens from their employees:
An overwhelming majority do the right thing for their patients, even at a high personal cost.
The author goes on to state,
By now, corporate medicine has milked just about all the “efficiency” it can out of the system. With mergers and streamlining, it has pushed the productivity numbers about as far as they can go.
Although the author is right about employee burnout, his view of corporate medicine is narrow. As popular as the Toyota Way has become, there are still an a large number of health care systems that have yet to begin their lean journey. Thus, the potential to create “efficiency” through the design of intelligent, evidence-based systems is huge. In other words, there needs to be a shift from working harder to working smarter. In the remainder of this text, we explore how to do so.
In the 1940s, during World War II, the United States brought together a national network of professionals from industry to develop techniques to quickly ramp up the production of war materials. This program became known as Training Within Industry and enabled a workforce of predominantly women to achieve astonishing results:
Let’s explore one of the primary methods of Training Within Industry known as JI or Job Instruction. Job Instruction is intended to help employees learn a job so that they can perform it correctly, safely, and conscientiously. To first do so, the job must be defined using a Job Instruction Breakdown Sheet (JIBS) as seen below.
In healthcare, prior to starting a job, it is essential to understand what is required to be done to the patient in the previous job. For example, in most health care settings, it is vital that a patient is verified and in the system for safety reasons. As such, in the JIBS above (part A), a patient requirement or prerequisite would be that the patient is verified and in the system; typically indicated by them wearing some form of wrist identification. If this particular step in the job did not happen, then the employee would have to, first, complete this job in order to move on to theirs. This lapse in preceding job steps happens more-often-than-not and translates into increased safety risks and undue burden on employees. In fact, because it happens so often, employees often don’t realize that they are performing the work of others.
After the patient requirements and prerequisites are defined, it is time to discuss equipment, supplies and technology needed (part B) for the employee to do their job. Once part B is defined, a great method to deploy is 5S because it ensures everything needed to deliver exceptional patient care is in the room (and, conversely, everything that is not is out of the room) and in a convenient location to minimize wasted motion for the employee.
Following parts A and B, we can now define the work. Although, it is important to note that parts A and B lead to a lot of waste in healthcare and should not be neglected. Recently, during an engagement, we were creating a Job Instruction Breakdown Sheet for room change over that happens following patient discharge. During our value stream mapping exercise, our current state revealed that the change over process for a Tech took 15 minutes. However, when we defined the job instruction breakdown sheet and walked it through a simulation, we noticed that the job only took 2 minutes. So where was the additional 13 minutes spent? Following a closer look, we uncovered that the additional 13 minutes were wasted looking for the supplies needed to stock the room properly.
In our future state value stream map, we intended to have pitches for discharge every 2 ½ hours to meet the desired takt time and achieve the overarching goal of discharging nine patients a day. Thus, before the start of the day shift, the night Tech would need to stock nine discharge “change over kits,” so the day team could achieve the cycle time goal of 2 minutes. This solution proved to be perfect as the night Tech had less responsibility and more capacity. As a result, each day, a Tech would gain 1.95 hours back in capacity (13 minutes of waste x 9 patients / day). For this particular site, a complete hospital-wide rollout would mean one full-time employee worth of capacity saved. Keep in mind, this is simply one small process in a value stream with over 20 processes. The point here is that by ensuring each job is done correctly upstream and that rooms are set up appropriately, we can do more with less, challenging the myth that more employees translate into more capacity.
In part C, we define the critical steps that advance the work. In other words, what are the steps that advance patient care. In parts D and E, we describe the key points associated with each step and the reason why it is important to follow. For example, when washing one’s hands, certain guidelines may dictate how much of our hands we need to clean, for how long, and in which way. The why here is infection control.
Once all these parts of the job instruction breakdown sheet are completed, we are ready to train using job instruction using the following card.
Job instruction is hugely effective, as demonstrated by the results of WWII, and has started to find its’ way into healthcare. As such, it is essential that the job instruction process be followed without taking any short-cuts. As the card states, if the worker hasn’t learned, the instructor hasn’t taught. In other words, the supervisor should assume responsibility if their staff does not know how to do a job correctly, safely, and conscientiously. This approach is a paradigm shift in management, and as you can see from above, the rigor in training using job instruction is high. The team member is shown the job three times, each time going a layer deeper by adding key points, and the reason why. They are then asked to demonstrate the job four times just as the instructor performed the job. This allows the instructor time to correct any errors observed as the team member does the job multiple times. The process doesn’t stop there. They are then asked to try out the job unsupervised so the supervisor can follow up to ensure the learning has taken place. Many of our clients initially push-back and say they do not have time for such a disciplined process. They quickly take back those thoughts as they realize the alternative is waste, re-work, low-employee morale, and, eventually, the need to recruit, hire, onboard and train new employees, who will be met with the same challenges as those they replace.
Job Instruction Training is designed to teach people how to do a particular job by:
As described in our previous blog, Strategy for Healthcare: How to Achieve Complete Business Strategy, alignment in healthcare is critical. The job instruction breakdown sheet is a critical component that allows organizations to march towards a future state for the business. If you and your healthcare suffer from employee burnout or low employee morale, please reach out to W3 Group as we have experts in who can help.