How many of you have seen improvement teams do a wonderful job developing the future state or new process only to stumble at implementation?  It can be really disheartening for a team that has worked so hard during the kaizen event.  There are many reasons why this can occur and I will focus on one of them for this blog.

It is about the hand-off and getting the front line staff knowledgeable about the new work standards.  How should it be done and who should do it?

The “how” involves communicating the new process to those who will be doing it and getting them up to speed with the new knowledge and skills required by the standard work.  This can’t be left to chance or assumed after the final improvement team report-out.  Achieving a successful implementation and stabilization of the new process requires effective instruction (covered below) and coaching (covered in a previous blog article, “The Blind Spot”).

There is a very effective tool for lean healthcare that can be used to instruct the team in the new process.  It was developed more than 70 years ago in the United States in the Training Within Industry (TWI) program and is still used today.  During the second World War the United States was sending a lot of its skilled workers overseas to fight.  Productivity in U.S. factories was suffering at a time when it needed to increase output.  The U.S. needed a way to develop skilled workers as quickly as possible to do the work of those who left to fight in the war.  By using the scientific method with lots of trials, the TWI engineers developed an approach that was able to develop job skills in new workers very quickly called Job Instruction Training (JIT).

This approach involves breaking down the work into 3 components:

1. Important Steps

2. Key Points of each step

3. Reasons for each Key Point

It is recorded on a Job Breakdown Sheet and used to provide a standard approach to skills development.


 The process for instruction involves eight steps:

  1. Tell and show each important step one at a time
  2. Tell and show each important step with key points
  3. Tell and show each important step with key points and reasons for the key points
  4. Have them try the process while you correct
  5. Have them explain the important steps
  6. Have them explain the key points
  7. Have them explain the reasons for the key points
  8. Repeat, correct, check on their progress, encourage them and coach to stability

Having a process for recording the future state standard work concisely, making it visible, providing the instruction and coaching the staff in the new work will greatly improve the likelihood of success.  A job breakdown sheet can help the instructors deliver a consistent message and process for staff instruction and serve as an ongoing reference for the standard work.

Who is responsible for providing the instruction for the front line staff in the new work processes?  A potential cause of failure involves the disconnect we see occasionally between the improvement team and the local managers.  The handoff between the improvement team and management is critically important and often overlooked.   Processes need to be continually monitored, measured and reinforced long after the improvement team’s work is done.  If this doesn’t occur, the improvements will likely deteriorate over time.

Management needs to assume these responsibilities and therefore need to be involved in the rollout and instruction phase of the improvement.  The improvement team needs to see to it that the local management has what they need to be able to sustain the future state work.  That involves:

  • Knowledge of the future state (think about the use of the job breakdown sheet here),
  • A method for instructing the staff (think about the use of Job Instruction Training),
  • Skills in coaching people in the new skills (think about the earlier blog article on coaching), and
  • Skills in visual management/measurement and finally the time to do so all of this (which will be the subject of a future blog article).

Job Instruction and management handoffs are important components to any process improvement activity in lean healthcare or in any other industry.  If not done, the risk of failure is high.  Building instruction, coaching and hand-offs into the improvement team’s work can increase the likelihood of sustained success.

This week’s blog was written by Dave Munch, M.D. and HPP Senior Vice President and Chief Clinical Officer.

Dave oversees all of HPP’s clinical and Lean Healthcare engagements. He plays a lead role in new services development and HPP’s continuous adaptation to the healthcare industry’s ever-changing needs.  Dave previously served at Exempla Lutheran Medical Center as their Chief Clinical and Quality Officer.   Dave has been a frequent speaker on the subject of leadership effectiveness and Lean transformation for a number of healthcare organizations including Institute for Healthcare Improvement (IHI), The University of Rochester Medical Center, Yale-New Haven Health System, Tulane University Medical Center, Pittsburgh Regional Health Initiative, Institute for Clinical Systems Improvement (ICSI), and the Voluntary Hospital Association (VHA).  Dave has served on the Agency for Healthcare Research and Quality’s High Reliability Advisory Group, has an extensive background in hospital operations, health plan governance, physician organization governance and clinical practice in Internal Medicine. 
Dave received his M.D. from the University of Colorado’s Health Sciences Center. He is also a faculty member for the Belmont University Lean Healthcare Certificate Program.
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