Japan: The Tyranny of Manual


Author: Tamotsu Ito

Positive Deviance Facilitator, Six Sigma - Master Black Belt, and Business Consultant



Aging society is one of many common adaptive issues in developed countries. In Japan as of 2017, 27.7% of the population are elderly people (65 years old and over), and elderly people can utilize social security system for their good lives. However, in the field of elderly care, elderly care staff cannot concentrate on their work properly such as taking the time to have deep conversations with elderly due to their daily work at hand, and troublesome relationships with their colleagues. As a result, some of the staff lose their motivation to work and leave the field of elderly care.

There are also Japanese manufacturing companies that run nursing homes for business opportunities or as a part of welfare benefits for their employees. In such nursing homes, "Kaizen"* efforts which is strong point for Japanese manufacturing companies are conducted to standardize their work and to develop manuals, but still it is difficult to run well.

*Kaizen, also known as continuous improvement, is a long-term approach to work that systematically seeks to achieve small, incremental changes in processes in order to improve efficiency and quality.


Define: What is the problem in community?

A Japanese manufacturing company had also conducted "Kaizen" efforts in its nursing homes which is run by their subsidiary company. However in its nursing homes, this manufacturing company had many problems like typical nursing home as explained above. At one of those nursing homes, a PD facilitator and the nursing home staff have launched a project to solve that, the discreet problem they identified is the following: "Bathing assistance cannot be completed within the specified time". For Japanese people, soaking in a hot bathtub is very important both culturally and as a way to maintaining their quality of life. Therefore, it was a difficult work to speed up bathing assistance simply and quickly.

When we launched the project, elderly care staff was able to complete bathing assistance in the specified time only in 50% of cases.

We conducted the “brown paper session” * with elderly care staff to share the common process of bathing assistance and their context such as other related problems. In this nursing home, they had good manuals for bathing assistance based on “Kaizen” efforts so far, then we could make the brown paper session very smoothly.

 *Brown paper session is one of Kaizen tool for the process mapping to share the details of work and problems using the sticky notes and the long brown kraft paper which is used for wrapping in the field of logistics.

Overview of bathing assistance from the manual:

  1. Preparation – Check vital signs and decide whether to take a bath
  2. Toward bath – lead elderly from their room to bath
  3. Bathing – Assist bathing
  4. Dressing – Support their dressing after bathing and ask elderly to drink water
  5. Back from bath – lead elderly to their room
  6. Cleaning up – If necessary, clean up the bath

Related problems – Voice of elderly care staff:

If we exceed the specified time of bathing assistance, we cannot always take a break!”

“If we have a bathing assistance session in the morning, elderly cannot often have a lunch on time!”


Determine: Who are “Positive Deviants”?

We measured the time of bathing assistance by different elderly care staff according to seniority such as: newcomers (less than 1 year of experience), moderate (experience 1 to 3 years) and expert (3 years or more experience). We found that newcomer staff were spending long time for bathing assistance. In typical problem solving like “Kaizen”, we will analyze the root cause of long time for bathing assistance and create the solution to eliminate it. If it is the field of manufacturing, that methodology will be correct. However, it may not be always true in the field of a service or medical care industry.

Here, we "flipped". We did not focus on the failure cases and root causes. Instead, we tried to find individuals or groups with uncommon but successful behaviors or strategies with less resources.

We found that two of moderate staff, who have less experiences of elderly care than experts, could complete bathing assistance within the specified time. However, we were concerned about that they might be just deviants to make it quickly. Therefore, we asked the elderly themselves and their families about these uncommon behavior in work. Fortunately, they had been highly appreciated.


Discover: How does “Positive Deviant” make small hidden success?

We were able to identify two staff as Positive Deviants. 

How did they complete bathing assistance within the specified time? At first, we had an interview session with the 2 PD staff about secret of small hidden success, but they said, “I always follow the manual”.

Therefore, we conducted some shadowing session to observe how each staff performed bathing assistance. Because the PD facilitator could not conduct it due to the privacy of elderlies, the staff leader who is also project leader conducted some shadowing session on bathing assistance day by day. 

And one day, the PD facilitator received an urgent e-mail from the staff leader that said: "I'm facing a serious thing. PD staff are not following the manual!"

The PD facilitator made a phone call to the staff leader soon afterwards and heard the details. Here are the results of the staff leader observations:

Expert staff:

Even if the elderly said that “I want to drink something” during checking vital signs, expert staff skillfully led them to bath. And they asked the elderly to drink water during dressing after taking a bath according to the manual.

Newcomer staff:

When newcomer staff were facing a similar situation, they had repeated arguments with the elderly and they needed more time to move from their room to bath. Also, when other newcomer staff asked the reluctant elderly to drink water during dressing, they had repeated argument with elderly and they needed more time to return from bath to their room. Newcomer staff said, “Please, drink water during dressing. This is manual!”

Elderly said, “No, I don’t. I drink something as I like!”

PD staff:

If the elderly said that “I want to drink something” during checking vital signs, PD staff provided what they want to drink and went to bath together. Also, if the elderly did not want to drink water during dressing, PD staff asked elderly to drink water after they returned to their room and calmed down.

Certainly, the manual said, "Elderly should drink water during dressing”. However, to make bathing assistance within the specified time smoothly, PD staff were deviants from the manual. Why was elderly asked to drink water during dressing? To prevent elderly from being dehydrated, it was not necessarily to have to be "drink water" at the time of "dressing."

We never blame newcomers with little experience. The newcomers were instructed to assist bathing according to the manual and they were keeping it honestly. However, it was making poor efficiency as a result.


Design: How can we involve the community to copy “Positive Deviance”?

We “flipped” again. To improve their operational efficiency of the nursing home, the standard operating procedure for bathing assistance was written in the manual, it was not wrong instruction. However, the project team decided to break up with their “How to” manual. Instead, project team said, “let’s make “Why so” guidebook that can be there for elderlies and clarified the reason to do so!”

However, not only to improve the efficiency of their work, but also to reduce the risk of poor quality elderly care work, they were keeping "How to" manual. Thus, we assumed some staff would resist to deploying “Why so” guidebook with top-down approach. So, we conducted a DAD (Discovery and Action Dialogue) session with staff. We asked them; “What do you do, if elderly does not want to drink water during dressing?”

This DAD session was an opportunity to find out why elderly should drink water in the bathing assistance process. And in this DAD session, we understood that expert staff were also deviants from the manual, when they were in situations that did not fit the manual.

Through the DAD session, we got acceptance from staff to deploy “Why so” guidebook. We also got some ideas from DAD session about how to train newcomers. We stopped the way that newcomers had to memorize the manual so far, instead, newcomers and their coach have a daily review of their work together using “Why so” guidebook. This method is called AAR (After Action Review).


Monitor: Have we sustainably solved the problem by “Positive Deviance” approach? 

We spread the Positive Deviance behavior like this, and improved the rate of completing bathing assistance in the specified time from 50% to 77.8%.

Where did this improvement come from? Not by expert or moderate staff. Newcomer staff has reduced the deviation of time by Positive Deviance behavior and their whole performance was improved. After this project, the PD facilitator understood who this project was for. Who was the poorest of the poor in this project? It was the newcomer staff, who was thrown into the field of elderly care without enough training and directed by the manual. The PD facilitator thinks that this project was for them.

Improvement in completing bathing assistance within the specified time has not changed much. However, after this project, the staff and the leader said the following.

Voice of elderly care staff:

“Now, we can have a break almost after the work of bathing assistance.” 

“Even if we have a work of bathing assistance in the morning, elderly can have a lunch on time.”

Voice of the project leader:

“I feel that new staff can learn the work of bathing assistance quickly. And we have some comments from elderlies, like that " Recently, I can talk a lot with staff", but the time we sit and talk to them properly has not increased yet. Why?”


The background of such voices is that there is a small social change in the nursing home as small community, that is, the relationship between elderly and staff have been changed, the relationship between newcomer staff and their coach have been changed. PD facilitator believes so.

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