Pulling the Andon Cord

It’s been two years since we discussed our work to assure that nurses always have the medication to give to patients when they need it. In January of 2016, we reviewed the tremendous reduction in “missing medications” that had been achieved because of the improvement work in the pharmacy and our inpatient nursing units.

This week, on Lean Daily Management rounds, Maxine Lawson, our Assistant Pharmacy Director, explained to us that there had only been one missing medication to Unit 34 out of the last 400 medications dispensed! Only one defect in the system for that unit. How did they accomplish this? Redesigning the system to get to high reliability has taken some time. We suffered a significant setback after Epic implementation as many sub-systems had to be recreated. Today, we have now returned to our pre-Epic implementation state by studying the misses as they happen, during the day, to find the root cause and fix it so it doesn’t happen again.

Toyota gets credit for being the first company to perfect the study of defects as they happen to learn the cause of the issue. Before that, auto manufacturers would either find defects as the cars came off the assembly line or when their customers found the problem. Toyota implemented the Andon cord (now a button that can be pushed), that immediately stops the assembly line and brings managers to the person who pulled the cord, so they could study what happened and find a fix.

Now when the nurses on Unit 34 are “missing” a medication they need, they do the equivalent of pulling the Andon cord…they call the pharmacy. Maxine and her team immediately (during the day) go to the unit and study what happened. They then use what they learned to test changes to their system to assure that the miss doesn’t happen again. What Toyota learned and what we now know is that it is much better to study one defect well when it happens than to get sophisticated reports of many defects over time before scheduling meetings to figure out what happened and what we should do about it. I am very proud of our outstanding pharmacy team and our smart and hard-working nurses. Together, they are driving us to ever higher reliability! They are happy to help any group learn how to use the immediate Andon cord technique to make things better.

A Wonderful Friend and Colleague Heads to Retirement 
This Thursday was George Bayless’ last day at GBMC.

George joined GBMC’s Executive Leadership team about 11 years ago as Vice President of Finance.  With more than 30 years of corporate financial experience in the public accounting and healthcare industries, he was responsible for the development, implementation, and maintenance of accounting systems that provide for the financial control of the entities of GBMC HealthCare. George was also responsible for system-wide financial planning and the annual operating and capital budget processes.

George recently assumed additional responsibilities when he took over as Interim Chief Financial Officer prior to Laurie Beyer’s arrival. That’s the George everybody knows. He’s a person who will do whatever it takes to help his colleagues and our healthcare system. George is great learner and teacher.

Congratulations, George, and thank you for everything you have done through the years for your colleagues at GBMC, for our healthcare system, and for our patients!

Kudos to Laura Clary (again!)

I want to also congratulate Laura Clary BSN, RN, FNE-A/P, SANE-A, CFN, CPEN, Clinical Manager of our SAFE program, who was recently named Baltimore County Woman of the Year by the Baltimore Commission for Women. This program honors female residents of Baltimore County who have made significant, unique, and lasting contributions to their community. I echo Dr. JoAnn Ioannou’s words that it’s no surprise that Laura is repeatedly given accolades because she is an extremely knowledgeable nurse, scientist, and phenomenal team leader. Congrats again, Laura!