Strengthening Reliability and Sustainability: Integrating Training Within Industry (TWI) in a Quality Improvement Collaborative

Abstract

Introduction: Integrating process improvement tools into healthcare has shown promising results, yet the application of "training within industry" (TWI) still needs to be explored in this context. This study focuses on implementing job instruction (JI), one of the three components of TWI, within a large breakthrough series collaborative (BTS) in a middle-income country.

Methods: We evaluated the deployment of JI during a nationwide initiative aimed at reducing three critical healthcare-associated infections (HAIs)-central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infections (CAUTI)-across 189 Brazilian public intensive care units (ICUs). Our quality improvement (QI) project outlines the integration of JI to enhance the reliability of care bundles and empower frontline teams to reduce variation, one fundamental condition to maintain ongoing improvements.

Results: The implementation strategy included structured JI training for the hub's leaders, which facilitated the gradual adoption and customization of JI and visual management techniques into daily ICU care. We detailed the four stages of JI training, the content of each session, and how they were incorporated into the existing BTS framework alongside visual management tools. The mean compliance to prevention bundles exceeded 90%, and the project results reached an overall reduction of 44%, 52%, and 54% for CLABSI, VAP, and CAUTI, respectively.

Conclusion: Our findings suggest that JI can be seamlessly integrated into routine QI activities. This structure promotes consistency in carrying out each aspect of care bundles, preventing HAI and strengthening patient safety.

Keywords: healthcare-associated infections; improvement science; job instruction; quality control; quality improvement.

Figure 1

A. Job instruction card. The card needs to fit in the pocket (2.7 × 4.7 inches, folded up and laminated) and be used as a guide during the training. B. An example of a job breakdown sheet for “scrub the hub open system.” C. Bundle element certification.

Figure 2

An example of job instruction first-year training plan for central line–associated bloodstream infection.

Figure 3

Integration workflow between the driver diagram, the Kamishibai cards, and job instruction.

Figure 4

Elements of bundle reliability for central line–associated blood stream infection (CLABSI)–run chart June 2022 to December 2023–aggregated data from 189 intensive care units. CLCI3a: Percentage of “evaluate the indication for central venous catheter insertion”; CLCI3b: Percentage of “select the most suitable location for central venous catheter insertion”; CLCI3c: Percentage of “use full-barrier precautions during central venous catheter insertion”; CLCI3d: Percentage of “use chlorhexidine for skin preparation”; CLCI3f: Percentage of “perform appropriate dressing after insertion.”