Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care, 1st Edition (Paperback) book cover

Getting to Standard Work in Health Care

Using TWI to Create a Foundation for Quality Care, 1st Edition

By Patrick Graupp, Martha Purrier

Productivity Press

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Addressing the challenges involved in achieving standard work in health care, Getting to Standard Work in Health Care: Using TWI to Create a Foundation for Quality Care describes how to incorporate the most widely used Training Within Industry (TWI) method, the Job Instruction (JI) training module, to facilitate performance excellence and boost employee morale in a health care organization. It not only examines the JI methodology but also explains how this program is as vital and applicable in today’s health care environment as it was when it was developed to train replacements of an industrial workforce off to fight in WWII.

Placing this methodology squarely within the health care paradigm, the book uses easy-to-understand terminology to describe how this method can make all the difference inthe delivery of quality health care. Supplying the foundation for successful Lean practice inhealth care, it clearly defines the role of standard work and training in relation to Lean health care.

The text includes case studies of current TWI usage in health care that demonstrate how to successfully roll out a sustainable Job Instruction initiative. Containing numerous examples of Job Instruction breakdowns in health care, the book provides you with the understanding of how to use this time-tested methodology to improve training, increase efficiency, and decrease strain in your organization.

CRC Press Authors Speak

Patrick Graupp and Martha Purrier discuss their book. Watch Part 1

Watch Part 2


Martha and Patrick combined their years of experience in Patient Care and Training to look at how the Training Within Industry’s Job Instruction program supports three critical needs at Virginia Mason Medical Center: engineering safety into patient care, more effective training for new caregivers and continually updating best practices for veteran employees to turn best practices into actual practices. In their own words: ‘…with our emphasis on improvement and the creation perfect care, we will show how the TWI method of Job Instruction is indispensible to the achievement of what needs to be done in healthcare today.’ This breakthrough book is a must read for all healthcare providers.

Robert J. Wrona, Executive Director, TWI Institute; and Author of The TWI Workbook: Essential Skills for Supervisors and Implementing TWI: Creating and Managing a Skills-Based Culture

The methods of Training Within Industry hold tremendous promise in transforming how we prepare our healthcare workforce to succeed in their work. Healthcare leaders demonstrate respect for people when systems are established that provide adequate and effective training for essential skills. The traditional methods of posting a memo or holding a brief in-service have not successfully demonstrated transference of knowledge and practice, leading to ongoing safety and quality issues for our patients. There is a rich difference between telling while showing vs. posting instructions as it relates to effectively changing the practice. 

Having served as a trainer utilizing the methods of TWI, there are added benefits of spending time on the gemba and understanding the barriers our staff encounter when attempting to do the right thing. The quality and quantity of information that came to us from simply being out and understanding their experience and conditions were invaluable. Every healthcare system should understand and utilize the methods of TWI.

—Charleen Tachibana, RN, MN, Senior Vice President, Chief Nursing Officer, & Hospital Administrator, Virginia Mason Medical Center

Table of Contents


When Clinical Best Practice Is Not Actual Practice


Engineering Safety into Our Care

More Effective Training for New Caregivers

Training Veteran Employees in Clinical Best Practices


Art of Medicine: It’s the People


"Pit Crews, Not Cowboys"

Where Things Go Wrong

Where We Go from Here

Hand Hygiene Training Case Study


Initial Training and Insights

Hand Hygiene: The Right Place to Start

Training Rollout

Results of the Initial Rollout

Handwashing Pilot Created "Pull"


Need for Good Instruction Skill


TWI Application in Health Care

From Manufacturing to Health Care

Good Job Instruction Technique


Four Steps of Job Instruction


Showing Alone

Telling Alone

A Sure and Effective Method of Instruction

Teaching Hand Hygiene

Step 1: Prepare the Worker

Detail 1: Put the Person at Ease

Detail 2: State the Job

Detail 3: Find Out What the Person Already Knows

Detail 4: Get the Person Interested in Learning the Job

Detail 5: Place the Person in the Correct Position

Step 2: Present the Operation

Detail 1: Tell, Show, and Illustrate One Important Step at a Time

Detail 2: Do It Again Stressing Key Points

Detail 3: Do It Again Stating Reasons for Key Points

Caution Point: Instruct Clearly, Completely, and Patiently, but Don’t Give Them More Information Than They Can Master at One Time

Step 3: Tryout Performance

Detail 1: Have the Person Do the Job, Correct Errors

Detail 2: Have the Person Explain Each Important Step to You as They Do the Job Again

Detail 3: Have the Person Explain Each Key Point to You as They Do the Job Again

Detail 4: Have the Person Explain Reasons for Key Points to You as They Do the Job Again

Caution Point: Make Sure the Person Understands

Caution Point: Continue Until You Know They Know

Step 4: Follow-Up

Detail 1: Put the Person on Their Own

Detail 2: Designate Who the Person Goes to for Help

Detail 3: Check on the Learner Frequently

Detail 4: Encourage Questions

Detail 5: Taper Off Extra Coaching and Close Follow-Up

If the Worker Hasn’t Learned, the Instructor Hasn’t Taught

Breaking Down a Job for Training


Get Ready Point 2: Break Down the Job

What Is an Important Step?

What Is a Key Point?

Important Step 1: Wet Hands

Important Step 2: Apply Soap

Important Step 3: Rub Hands

Important Step 4: Rub Fingers

Important Step 5: Rinse

Important Step 6: Dry

Summary and Sample Breakdowns

Breakdown Sheets and Standardized Work

Finding the Key Points: The "Key" to Good Instruction


What to Include and What Not to Include

Simple Words and Few

Teaching "Feel"

How Many Key Points in a Single Step?

Common Key Points

Observing and Involving Experienced Workers in the Breakdown Process

Training Soft Skills: Hourly Rounding to Prevent Patient Falls

Getting Patients to Ask for Help

"We’re Too Busy to Do This"

Patient Falls Were Reduced

How to Organize and Plan Training


Get Ready Point 1: Make a Timetable for Training

Get Ready Points 3 and 4:

Get Everything Ready and Arrange the Worksite

Training Large Jobs: Divide Them into Teaching Units

When, and When Not, to Use Job Instruction

Implementation of New Equipment: Everyone Does It the Right Way


Starting Out Strong with a Pilot Project


A Plan for Continuing Results

Getting Started on the Right Foot

Form a TWI Working Group Responsible to Lead the Way

Select a Pilot Project to Show the Need for Standard Work

Initial Delivery of TWI Training

Create In-House Trainers

Create a Rollout Plan and Spread the Training

Integrating JI into the Culture to Sustain Results


TWI as a Common Language

Using the Tools of Lean with TWI

Standard Work Sheet

PDSA (Plan-Do-Study-Act) Cycles

Standard Work

Target Progress Reports

Cycle Time

Takt Time

Root Cause Analysis (RCA)

Sustaining Improvement

Conclusion: A Call to Action


About the Authors

Patrick Graupp began his training career at the SANYO Electric Corporate Training Center in Kobe, Japan, after graduating with Highest Honors from Drexel University in 1980. There he learned to deliver TWI and other training to prepare employees for assignment outside of Japan. He was transferred to a compact disc fabrication plant in Indiana, where he obtained manufacturing experience before returning to Japan to lead SANYO’s global training effort. Graupp earned an MBA from Boston University during this time and was later promoted to the head of Human Resources for SANYO North America Corp. in San Diego, California, where he settled.

Graupp delivered a pilot project in 2001 to reintroduce TWI in the United States. The positive results of the pilot project encouraged him to leave SANYO in 2002 to deliver the TWI program on a wider scale throughout the United States in the same manner as he was taught in Japan. He described in his book The TWI Workbook: Essential Skills for Supervisors, a Shingo Research and Professional Publication Prize Recipient for 2007. Working with the TWI Institute of Syracuse, New York, Graupp developed standardized training manuals and materials to train and certify trainers on how to deliver the TWI modules as was done by the TWI Service during WWII. The TWI Institute has since trained hundreds of trainers across the United States and around the globe that led to his follow-up book, Implementing TWI: Creating and Managing a Skills Based Culture, that was published in October 2010.

Martha Purrier is a registered nurse with over 25 years of experience in the hospital setting. She earned a master’s degree specializing in the clinical care of patients with cancer and in the training of nurses. During the past 12 years, she has worked at Virginia Mason Medical Center in Seattle, Washington, as the director of Inpatient Oncology and IV Services. Virginia Mason adopted Lean as a management methodology in 2001 and Purrier was certified in Rapid Process Improvement Workshops in 2006. During her work in IV therapy, the team won the Mary McClinton Patient Safety award for the application of Lean methods, which produced increased safety for patients receiving central lines. In 2008, Purrier was appointed to the Kaizen Fellowship Program. She currently works as the director of Virginia Mason’s Kaizen Promotion Office and is applying TWI to health care instruction. She is a certified instructor of the TWI Job Instruction program.

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Quality Control
BUSINESS & ECONOMICS / Industries / Service Industries
MEDICAL / Administration