What the andon cord asks the person in charge

A worker who sees a defect is supposed to stop the work, and a leader is supposed to arrive while the job is still in front of them. Virginia Mason spent years trying to make that normal in a hospital, after watching it on a Toyota factory floor.

In 2002 Gary Kaplan, the chief executive, took executives to Japan for two weeks. Cathie Furman, senior vice president of quality and compliance, watched assembly workers stop the line and fix the problem with the people beside them, instead of passing a defective car along. In the Virginia Mason Institute case study she describes high-school-trained workers who would halt a multi-million-dollar line rather than hand a defect to a teammate, and a blaming, hierarchical culture in the health care she knew. She also asked the obvious question. If everyone in a hospital could stop the work, would the place ever get moving again?

The hospital already collected quality reports. Katherine Galagan, director of clinical laboratories, said they were often funnelled off and lost in the wash. Toyota's version of the signal is the andon: any employee can alert a manager or a colleague to a defect, small or large. Virginia Mason's version is the Patient Safety Alert, by phone or online, as soon as someone thinks a patient has been harmed or might be. New staff hear on the first day that reporting is the job.

The signal depends on the reply. In 2005 a nurse saw a physician skip the protocol for a procedure and asked him to stop. He refused. She called an alert. The leader who answered thanked her and ordered the procedure stopped. He stopped, then berated the nurse. She called a second alert, about that. The leader thanked her again and took the physician offline. The hospital investigated and trained him. The case study says that from then, more people believed a stop would be backed.

The institute's 2018 account gives the scale of what followed. In September 2014 the hospital logged its 50,000th alert. By the end of that year the average was 879 a month, against a goal of 1,000. Survey participation rose from 16 percent in 2004 to 88 percent in 2013, and 80 percent of respondents that year said they speak up freely if they see something that may affect a patient. From May 2005 to May 2015, professional liability claims fell 74 percent.

Furman and Robert Caplan wrote that those results depended on keeping the door open, because the person who saw the issue is the one who knows whether it matters. Brenda Simon, in human resources, called an alert about loose tape on a stair. It was fixed the next day. Henry Otero, a physician, filed one on himself after he missed a low magnesium level on a cancer patient. The case study treats that kind of defect as a process problem, so a self-report does not come with a punishment. Kaplan's line in the account is that staff will only keep inspecting the work if executives support it around the clock. Board member Julie Morath said events stay open until the board says they are closed.

1. Give people one obvious way to signal, and say on day one that using it is part of the job.
2. Thank the person when the signal arrives. The 2005 case turned on the second alert, the one about the punishment.
3. Fix small things where others can see the repair. Tape sorted by the next day teaches more than a poster.
4. Let people report their own miss. If the only safe report is about someone else, the person closest to the error will soften it.
5. Leave serious alerts open until a senior person closes them. A report that disappears into a department is the system Galagan described.

A psychological safety session is a useful place for an intact team to practise that reply on a live miss. Bring the last one the team already knows about, and agree what the person who answers will say.