Training Within Industry (TWI) at Erasmus Medical Center

Published on
July 12, 2022
Stefan Visser
Stefan Visser
Stefan Visser is a trainer/consultant at LMI
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As part of the recent reorganization at Erasmus Medical Center, four surgical specialties (plastic, orthopedic, dermatology and traumatology) were integrated into one nursing unit. Although our nurses now have the opportunity to specialize in four different disciplines, this also involves a lot of work to learn new skills. Combined with our high staff turnover - we recently had to induct 18 new nurses within three to four months, making up almost half of our 40 staff - this created the perfect opportunity.

The need to train new hires quickly and to help nurses learn new skills so they could easily work across the four specialties led us to explore new ways of training staff. One of the Lean techniques, Training Within Industry (TWI), proved to be the solution to our problems.

TWI in practice: focus on why

We started TWI in orthopedics. Our first step was to break down the thick manual that new people traditionally received for their onboarding into smaller parts that were more digestible.

As I wrote the work instructions for each procedure, it quickly became clear to me that what sets TWI apart from other training approaches is the "why" part. Explaining to people why they should perform a particular step in a process is what ultimately makes the difference and helps them remember the standard.

Standardization of work and skills matrix

With new people joining us regularly, standardization of work has become paramount for us. Not only because it ensures that everyone works the same way, but also because it allows us to easily track each nurse's progress. A skills matrix allows us to assess everyone's skill level and fill in the gaps as needed. This tool helps us gradually bring everyone to the same skill level. (For the organization, TWI means that we have been able to set clear operational goals specific to people development, whereas traditionally we only set qualitative goals).

For example, if a nurse lacks certain skills in one of the four disciplines we cover, TWI immediately tells us what those skills are and allows us to create a development plan tailored to that person's needs. In that sense, it gives everyone a path for self-development, with self-assessment and one-on-one coaching to make sure they are on track. People love TWI not only because it gives them detailed information on how to do the job, but also because they now have a learning path to follow.

We have been running the TWI program for about 10 months (with the help of the Lean Management Institute), and the rest of the hospital is already showing interest in starting it in other departments. I also presented it to management, and it was very well received.

Result: A3 thinking and real problem solving

From an operational standpoint, I can say with confidence that as we become more accustomed to standards, we get better at finding problems. With A3 thinking (another approach our people love), we are then able to solve those problems once and for all, learning to identify root causes so that they don't crop up later.

Result: retaining talent

Another obvious benefit of TWI lies in recruiting and retaining talent. Being a nurse is tough: the work itself is naturally demanding, and the initial training rigorous. Traditionally, many people left the program after one or two months, but with TWI we see fewer and fewer dropouts. At job interviews, we even hear that people are interested in coming to work here precisely because of our TWI training: it makes the course less daunting, especially for professionals coming to the hospital from elderly care (for them, the jump is normally greater).

There is no doubt that TWI is a strategic asset for our hospital, as it helps us retain talent and even attract new people - which is incredibly important for an organization with high staff turnover. When we started, I never thought it would be such a success, and I couldn't be happier to see Lean working so successfully in our department.

Result: focus on customer value and continuous improvement

Our efforts with TWI are of course part of the broader Lean transformation of the organization (you can read more about it in this interview with our director Kjeld Aij).

Much of our Lean work is focused on putting more and more emphasis on patient value. In our department, we conduct many patient surveys, and we have used the results to determine the next steps in our continuous improvement journey. When one of our patients raised the issue that nurses were not visible enough (analysis of the problem showed that they only spent 25 minutes a day with patients), that immediately became the focus of one of our A3s.

When I started working here, we always looked at problems from the hospital's point of view-it was very inward looking-while now we look at what our patients need and tell us. We are trying to change our perspective and have recently started inviting patients to our department to share their experiences with the care they receive.

I think our greater emphasis on standardization and customer value for patients will increase the number of opportunities for improvement. The lessons we learn from our patients and from our past mistakes shape our standards: the top three patient complaints, for example, led to two new tasks that we incorporated into our work instructions.

We see the TWI program as more than just training: we see it as real learning-by-doing (and improving).

Tineke Moerman (left) is Quality Officer and Melissa Masson is a Nurse at the Erasmus Medical Center in Rotterdam.
Courtesy of Tineke Moerman and Melissa Masson.
Tineke Moerman (left) is Quality Officer and Melissa Masson is a Nurse at Erasmus Medical Center in Rotterdam.

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