LeanHealthcare_andonIn 1984 Toyota and General Motors created a joint venture assembly plant in northern California known as NUMMI (New United Motors Manufacturing Incorporated).  The plant, which was previously known as one General Motors’ worst, was winning awards for quality and reliability with essentially the same workforce and facility.

Everyone building anything was flocking to NUMMI in the 80’s to see if they could learn what was driving the success of this assembly plant.  One of the things that visitors saw was a fancy communication system known as andon.  Line operators could pull a cord in their job station and things would go crazy.  Music playing, lights flashing, and huge electronic boards notifying everyone that someone had pulled the andon cord.

This was why NUMMI was so successful. This was the magic.  The silver bullet.  It was shortsighted to think that this tool, which is only a part of the Toyota Production System, could change culture overnight, but that was the thinking.  So “andon” systems costing millions and millions began to be installed in assembly plants across the country.

I worked for General Motors during this time and this was my first exposure to the Toyota Production System.  Now, let me preface my remarks by saying that it didn’t take too long for my employer to figure out and utilize TPS methodology to build world class vehicles in world class assembly plants – which they continue to do to this day utilizing the same methodology.

However, in the early days, we just didn’t get it.  I was a general supervisor in those days responsible for six supervisors and 250 assembly line workers.  We installed the fancy light boards.  We put up the lines and the cords.  We divided into teams.  We picked out the music we would play if a particular cord was pulled.  We trained everyone in how the system would work — but we just didn’t get it.  As a mid-level manager, I thought, “What a great way for Joe to let his supervisor know he has to go the bathroom.”

So what happened?  Someone pulled the cord and the line stopped.  Someone else pulled the cord and the line stopped.  And it wasn’t very long before someone else pulled the cord and the line stopped.  And it didn’t start again for a long, long time.  We just didn’t get it.

Andon is a Japanese word which means “lantern.”  It has evolved to a connotation of a call for help.  Japanese lore has it that a long time ago the fishing boats would go out at dawn and come back at dusk.  As they were approaching the shore, they would hang lanterns from the boats which could be seen from the shore and signal the people in the village how much help they would need to unload the catch.  The lanterns were the signal for the call for help.

Toyota realized that in building cars problems were always going to arise in the manufacturing process that would keep an operator from completing their job.  Instead of letting that defect go to the next operator where it could likely cause other defects or to an inspection station where hopefully it was identified, the operator could call for help.  “I can’t do my job.”  Giving that operator the ability to signal there was a problem really was a silver bullet.

Andon philosophy is that no defect will be passed on to the next customer.  Andon provides a means of signaling for help when a quality or process problem is identified (or when a performance standard is compromised).

This is essential in Lean Healthcare practices.  It is a fundamental premise of a Lean management system.  We should never pass on a defect to our customer.  The customer is not only the patient and the family, but the customer is also the next stop in the patient pathway.

Andons have three components: thresholds, triggers and responses.

Threshold:  Observable evidence of a problem or a failure that may occur or has occurred.

The threshold is the point where a signal is given that help is needed.  It is critical that the threshold be prior to the problem manifesting itself to the point that control is difficult.

In healthcare, a common scenario is patients waiting for triage in the ED.  There are multiple ways to look at this.  It could be time waiting.  It could be the number of patients waiting.  If we know we are in the ditch when we have fifteen patients waiting for triage then we need to react well before fifteen.  Observation, experience and analysis might set our threshold at ten patients waiting for triage.  Ten patients waiting and we “pull the cord.”

Another example I have seen is on a nursing unit during med pass.  The nurse’s cart had a flag she could raise to signal she was behind on her med delivery and needed help to get on schedule.  The threshold is pre-defined as to what “behind” means so it is clear when to ask for help.

Trigger:  Who has the authority to react to the issue.

It is a bit confusing because one might think that the trigger and threshold are the same thing.  But the trigger is who (or what, if it is automated) is authorized to pull the cord and send the signal.

In the scenario in the ED it is likely to be the charge nurse.  Someone who sees the big picture and has the authority to put reactions in motion.  In many other scenarios, it can and should be the nurse who signals for help.

In the med pass scenario, the trigger is the nurse that realizes she is behind in her med pass and thus pulls the trigger by raising the flag.

Response:  The pre-defined response or set of actions.

What do you do when the light goes on and the music plays?  How do we react and fix the problem before it manifests itself by stopping the process all together?

In our healthcare scenario, the response might be redeploying nurses to triage.  This is part of the standard work that might be a pre-diversion plan.  Specified responses to react before the need for diversion is upon us.

For the med pass andon, the response is predefined perhaps for a charge nurse, nurse or manager to support.  The key is that there is a defined response.

The Response was the component we didn’t understand in our early attempts of andons at GM.  We didn’t understand the support.  The mindset that a planned reaction is put into motion before the threshold is passed and the problem is upon us.  We didn’t have good planned standard work responses and thus the line stopped because we were unable to fix the problem and keep it from recurring.  Or, we broke all the rules by letting the line run and essentially passing on the defects to the end of the line where they could go undetected and shipped to the final customer.

Andons are such an incredible Lean tool and combine the features of many of the fundamental Lean principles.  They use visual management to display when the signal is given.  Standards are the basis for defining the thresholds.  Standard work is the key component of the trigger and the response.  Leadership standard work ensures the andon is followed and functional for the purpose.  Not to mention the observation, A3 thinking and root cause analysis that go into defining the standard work.

Right now in your own healthcare setting I am sure you can name andons that are already in use.  But I challenge you to define the threshold analytically, to empower the trigger and provide standard work for how to signal.  Most importantly, define the response with clear written standard work that can be trained and verified as effective.

Andon is a means to empower the staff to do something that it is seemingly very difficult to do in healthcare.  That is to “call for help.”  Our staff are conditioned to doing whatever it takes for their patients without asking for support.

In a Lean Healthcare environment the teamwork and cohesiveness enable the staff to work together to be proactive and respond to issues before they are out of hand.

“Pulling the cord” to communicate “I need help” is a key tool to empower our staff and improve our patient experiences.


Steve Taninecz, Director for Lean Healthcare and Process Improvement at HPPToday’s blog was written by Steve Taninecz, director at HPP.

Steve has 40 years of experience in healthcare and manufacturing organizations.  Steve’s work in the healthcare field began as an educator, trainer and coach for the Pittsburgh Regional Health Initiative, then as part of a New England for-profit health system overseeing, counseling and coaching culture change to the hospital system’s leadership for the successful implementation of lean.  Steve holds a Bachelor’s Degree from Youngstown State University in Industrial Management and a Master’s Degree in Organization Leadership from Geneva College.

Image: The New York Times

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