A Breakthrough in Training — Call it "Near-TWI"


I'm very pleased to present a guest post from Arizona about the successful use of Lean concepts and, more specifically, the “Training Within Industry” methodology. You may recognize Dr. Pete as a regular commenter here on the blog. We've spoken a number of times by phone about the lab's work and I invited Dr. Pete and Chuy to document some of their collaborative work here on my Lean Blog. If you have questions, post a comment and I know Dr. Pete will be glad to interact with you.

A Breakthrough in Training — Call it “Near-TWI”

By: Jesus “Chuy” Ellin, HT PA & Peter P Patterson, MD MBA

The histopathology laboratory at our hospital recently had a breakthrough in the lean journey we began in 2007. The monthly defect rate in the order entry process has fallen precipitously from 33.5% to 2.5% over the past five months, after we initiated comprehensive new employee training.

The order entry person in our laboratory is responsible for logging in patient samples and setting them up for processing and subsequent slide production. The position had chewed up six people in three years — no one seemed to last more than a few months. The high rate of mistakes in order entry necessitated a great deal of rework and delay. This was a constant source of friction between the histology laboratory and transcriptionists in the office. Our conventional management wisdom was that we just could not seem to find good people. We did also notice that criticizing the mistakes and exacting various forms of employee discipline did not improve the defect rate. Sound familiar?

When the order entry incumbent resigned without notice in November 2008, our management team began to seriously investigate the real sources of the high defect rate. A major insight was the realization that initial training of new employees was completely inadequate. Furthermore, many of the important aspects of the job were either undocumented or inadequately documented making effective training difficult.

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We began two efforts simultaneously — one was complete documentation of the correct procedures and steps; the other was initiating a way to engage the laboratory staff such that they became active players in the improvement efforts. Our motto became “everyone has a part to play”.

After documenting all the important steps in the order entry process, the new person hired in was carefully trained one-on-one by the supervisor over a period of weeks. The new hire was trained in a way that did not overwhelm her with new knowledge and yet no detail of the job breakdown was left out. Here, insights and detailed job knowledge provided by the staff helped shape the training content and sequence.

At the same time, the lab staff was asked to share their concerns, insights and recommendations for needed changes. One of the first results here was a list of tasks that needed to be completed every day, and an additional list that needed to be completed with a regular periodicity – say weekly. New visibility was given to uniform expectations regarding complete work around each task on the list. As the improvement process became much more interactive, the staff naturally had ownership of the updated lists.

In the first month after the new person was hired and trained the new way, the defect rate fell 72%. The next month it fell 17%. The defect rate has fallen by similar amounts each subsequent month, now five months running. As the defect rate falls to low levels, we have begun exploring the ideas behind a “zero-defect” program.

In researching the problem prior to the new hire, we tapped into the rich vein of TWI in Healthcare. Since we made the connection, we have opened a large body of knowledge which now informs the evolution of our work. We have refined our training efforts along the lines of the Job Breakdown Sheet (JBS) and Job Instruction (JI). New employee training was conducted in the four step TWI sequence: prepare the person, present the job, let the worker try it and follow-up frequently. We are realizing that the instructor has a defined job sequence just like the employee.

As our thinking and methods have developed over time, we see that we are evolving our own unique approach rather than simply trying to implement someone else's way. As we currently see it, the two pillars of our improvement system are: 1. Engage and develop your people. 2. Get continuously better at what you do. Over the course of multiple PDCA cycles, we have validated the principle that a well-trained workforce is the foundation for standardized work and kaizen.

Jesus “Chuy” Ellin, HT PA
Peter P Patterson, MD MBA

[Potential conflict of interest disclosure – the firm I used to work for, ValuMetrix Services, provided some initial consulting to their organization, although I was not directly involved in that consulting work.]

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. great story

    In the past we've put most effort in the processes
    recently we're moving to (include) continuous improvement

    now we realise we need to (include) the people aspect much more, including as you mention much more/better involvement, more training and the culture of respect.

    I especially appreciate your remark not to copy, but develop your own way. Thank you for your story, that helps our thinking.

    Marc Rouppe van der Voort
    St. Elisabeth Hospital, the Netherlands


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