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Systems Design

The high-impact, low-cost way to close the healthcare training gap

The Problem

According to the US Bureau of Labor Statistics, employment of healthcare occupations is projected to grow 14 percent from 2018 to 2028 [1]. This is much faster than the average for all occupations. However, healthcare workers receive a third less training than workers from other industries and healthcare executives spend half on training compared to their peers in other industries [2]. This deadly combination often translates into healthcare systems that are understaffed and poorly trained and the consequences are evident. According to Dr. David Bates of Brigham and Women’s Hospital, 15-25% of all patients are harmed in a healthcare setting and hospital harm is now the 3rd leading cause of death after cardiac and cancer. To make things worse, employee turnover is at an all-time high and is only projected to get worse. [3]

This perfect storm often puts healthcare executives in a precarious situation, left with one of two unfavorable options. Their first option is to ignore the problem only to see things get worse. Their second option is to invest time and money into training their staff. Choosing the second option seems obvious but comes with some major obstacles. Freeing up frontline staff for training when teams are understaffed is costly. It overburdens those who remain on the frontlines and could potentially lead to patient harm. Furthermore, how frontline staff members are trained is often highly ineffective, taking place in a classroom setting or via an online course. When faced with the risk of losing money while placing more burden on frontline staff members, we can see why many executives chose to do nothing at all.

Luckily, there is a third option.

The Solution

Healthcare executives would define an ideal training program as one that is:

  1. High-Impact
  2. Low Cost
  3. Nondisruptive

In other words, the training would enable frontline staff to perform core jobs safely, correctly, and conscientiously, be performed for a relatively low cost, and would not disrupt the delivery of patient care. The following training system achieves all three.

Image 1: The Kōhei Group Training System

Identify Core Job

The first important step when training is to answer the question what should we train? With healthcare’s growing complexity, answering this question may seem overwhelming. To help, we developed a simple tool as seen below.

Image 2: Job Identifier Tool

When using this tool, there are 5 important steps as detailed in the following table:

StepKey PointReason Why
Identify the patient typeHigh volumeCostlyHigh impact
Brainstorm jobsWith frontlinesAccuracy of data
Assign Impact scorePatient safetyPrioritization
Assign Impact scorePatient safetyPrioritization
AnalyzeFocus on high scoreHigh Impact

The first step is to identify the patient “type” to focus on. This could be done using a Diagnosis-related Group or DRG. There are all different types of patients that come into a healthcare setting, each with their own specific needs. The question of which group to focus on is a strategic one and leadership will have to answer this question. If the why behind training is to impact a high volume of jobs, then picking the most common patient type by volume is the direction to go. Keep in mind, there may be “core” jobs that span across a variety of patient types. However, if the why is the focus on jobs that have high failure modes and are costly when performed incorrectly, then picking a patient type with lower volume but who is high risk might make more sense.

Once the patient type or types is selected, leadership should work with frontline staff to brainstorm what jobs exist. It is helpful to have clinical leadership, both physician and nursing, present to weigh in on what jobs need to be done and to also assign an impact score to each job. Jobs should be assigned high (5), medium (3), or low (1) impact scores based on their impact on patient safety. During several shifts, frontline staff workers should capture how many times each job is performed. Multiplying this times the impact score will yield a rating score, which should be used to prioritize which job to begin defining.

Define How to Perform Core Job “Knowledge Capture”

One of the biggest risks in not creating an effective healthcare training system is that stored knowledge that frontline workers have is never shared or, even worse, lost should they leave the organization. In this second part of our system, we define the job with the highest impact score by capturing hidden knowledge and best practices that our frontline workers have. A team of high performers and clinical experts should be assembled to go through the exercise of filling out the Knowledge Capture tool as seen below.

Image 3: Knowledge Capture Tool

In this tool, we first list the job, enter a revised date, and a revision # as this document should be updated every time a new best practice or improvement is discovered.

Next, all the inputs needed from other peers to complete the job are listed along with supplies / equipment and tools. In healthcare, it is often the case that frontline staff members are unable to complete a job correctly because they do not have what they need to complete the job. This step is akin to receiving ready-to-assemble furniture, emptying the contents onto the floor, and ensuring everything needed to put the furniture together came with the package. If not, then the job cannot be performed. In a hospital setting, whoever is in charge of providing inputs or ensuring supplies, equipment and tools are available should be contacted to identify the root-cause of the problem, put in place a quick counter-measure, and systematize a more permanent solution moving forward.

Once everything needed to perform the job correctly is identified, we then begin to list all the steps that advance the work. For each step, key points and they reasons why should be captured. Key points are ways to do the job that will help avoid failure. For example, when checking blood glucose, a key point may be to massage blood towards the fingertip to ensure there is sufficient blood to get a reading and avoid having to retest the patient, i.e. the reason why.

It is important to note that the knowledge capture tool should be written in bullets points consisting of 1-2 words to jot a frontline staff worker’s memory. If there are parts of the job too complex to remember, then a key point should point to a checklist or job aid that the employee remembers to reference for that step.

Prepare the Environment to Perform a Core Job

Now that we have selected and defined our first job, the next step is to organize the environment in a way that makes performing the job easy for employees. To do so, we leverage a tool from the Toyota car company that has been leveraged in the healthcare industry called 5S:

  1. Sort
  2. Set
  3. Shine
  4. Standardize
  5. Sustain
Image 4: 5S Checklist

In the first S, sort, we remove everything that is not needed to perform core jobs and deliver patient care. The knowledge capture tool can be used her to identify what supplies, equipment, and tools are needed. Everything else should go. If it is not used it is clutter and will make the work harder on the frontline staff.

In the second S, set, all remaining supplies, equipment, and tools should be placed as close as possible to the point of patient care to minimize motion and ensure proper ergonomics. In one Lean study, up to 50% of a nurse shift time was attributed to walking.

In the third S, shine, we work on defining a standard to clean the work pace. In healthcare, this is especially important to avoid the spread of infections and to provide safety to our employees and patients.

In the fourth and fifth Ss, standardize and sustain, we create a standard for performing the first 3 Ss as needed. It is important to note that 5S should be an input to any job we define. Leadership should do periodic reviews to ensure the first 3 Ss are getting performed to standard to ensure efforts are sustained.

Once 5S is complete, we should revisit the Knowledge Capture tool and run through the job several more times to make refinements to both the job and 5S. Upon doing so, we now have a standard work baseline on how to perform the job. This will be critical to continuously improving the work.

Train Frontline Staff on Core Job “Knowledge Share”

With the job selected, defined, and the workplace set up properly, we are now ready to train our employees. To do so, we use a tool called Knowledge Share as seen below borrowed from a World War II training technique called Training Within Industry.

Most traditional training fails because it either shows only or tells only. Our Knowledge Share does both in a way that drastically improve knowledge retention. In fact, according to the Training Within Industry Institute, companies using this form of training experienced the following[4]:

  • 86% increased production by at least 25%
  • 100% reduced training time by 25% or more
  • 88% reduced labor-hours by over 25%

So, what makes this form of training so effective? Simply stated, discipline. When training the learner, the teacher should demonstrate the job 3 times. The first simply performing the mechanics of the job; the second performing the mechanics of the job and stating key points; and, lastly, the third perming the mechanics of the job, stating key points, and providing the reason why. Each iteration should allow the learner to gain a

Image 5: Knowledge Share tool

deeper understanding of the job. When this is done, the learner should then perform a teach back, similarly demonstrating the job 3 times as done by the teacher.

As the learner performs the job, the teacher should correct them in real-time as to ensure bad habits are not formed. The learner should then be assigned to work on their own with a go-to “buddy” should they have questions and the teacher should follow up periodically to ensure they are doing the job correctly, safely, and conscientiously.

A Quick Thought on Simulation vs. at bedside

Ideally, training should happen at patient bedside for several reasons:

  1. It puts pressure on the unit to always have rooms set up to 5S standard or else the training cannot be performed correctly
  2. A simulation can never mimic the real situation
  3. We minimize the impact on team capacity by delivering care while we train

The key to training at bedside is to ensure the patient understands what is happening. Stating key points and reasons why in front of the patient is also a great way to educate them on their care and can have the added advantage of driving up patient satisfaction when done correctly.

Track and Monitor

Too many healthcare systems train and fail to track and monitor the efficacy of their training. In our system we leverage two tools to ensure that does not happen. The first tool is called a Skills Tracker as seen below.

Image 6: Skills Tracker

This tool is used to track all the jobs and the capability of front-line staff to perform those jobs. Whenever a job is newly defined or revised, a target date to train each front-line staff member should be set. Once they go through Knowledge Share training, the supervisor should conduct a process confirmation to ensure they can do the job per the standard. If they can, the supervisor updates the skills tracker to reflect they can do the job. The process confirmations should be done periodically to ensure front-line staff members continue to perform to standard and to fight against entropy.

Case Study In 2019, the Kōhei Group was asked to help a client in the Baltimore, MD area. Using the training system described above, we defined nurse hourly rounding as one of the most impactful jobs that impacted patient safety. Using the best-practice of 5 P’s of rounding, we defined the job using the Knowledge Capture tool and trained employees using the Knowledge Share standard. A skills tracker and process confirmations were used to ensure all the staff were performing the job to standard. In the matter of two months, hourly rounding went from 20% adherence to over 90% adherence and KPI (Key Performance Indicators) related to safety drastically improved with zero incidents of harm on the units that piloted the program.


Upon reflection, the system presented above is not complicated. In fact, each component, in-and-of-itself, seems so simple any one of them may be overlooked at face value. However, in concert, the components are immensely powerful, creating a healthcare training system that is indeed high-impact, low cost, and nondisruptive. For healthcare executives facing the dilemma of an understaffed and under skilled workforce, this system offers hope. Leadership commitment, coordination, and discipline are the key.

[1] https://www.bls.gov/ooh/healthcare/home.htm

[2] https://www.modernhealthcare.com/labor/health-systems-redefine-training-re-energize-employees

[3] https://info.workinstitute.com/hubfs/2019%20Retention%20Report/Work%20Institute%202019%20Retention%20Report%20final-1.pdf

[4] https://www.twi-institute.com/training-within-industry/training-and-certification/benefits-of-twi/proven-results/

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