By: Jamiu Busari MD, MHPE, PhD, FRCPC (hons) and Ming-Ka Chan, MD, MHPE, FRCPC
The Concept – Andon Cord
Consider jidoka, the Japanese principle of “autonomation” or “automation with a human touch,” central to the Toyota Production System (TPS). In this system, the production line is designed to automatically detect anomalies and halt operations through the use of the Andon cord (or switch). This approach to continuous quality improvement (CQI), often referred to as lean management, embodies co-creation, where any worker on the Toyota assembly line can halt production when an abnormality is detected and address the issue in real-time. Imagine a system where the worker who pulls the andon cord on the assembly line has the freedom to escalate the problem to their superior if they fail to solve/mitigate the problem. This process, a cornerstone of the renowned TPS, ensures consistent quality across Toyota’s vehicles and has become a benchmark for excellence in the automotive industry. The technology has also been successfully applied in healthcare systems, such as the Virginia Mason production system.
CBE as a Learning Assembly Line
So, how might we apply the Andon cord’s CQI model to medical and health professions education in competency-based education (CBE)? How can we apply the principle to support the developmental stages of the learner and ensure quality in the trajectory from student to medical or health specialist? Let us start with the presumption that the trajectory of CBE represents an “assembly line of learning” that is designed to produce forward-thinking health professionals who ultimately should become independent and competent change agents.
Currently, the CBE assembly line trajectory represents a high-stakes journey for learners. However, it includes elements that are misaligned with the educational process, leading to poorly functioning—and at times even dysfunctional—learning systems. Bias is one such element that directly shapes learners’ experiences. Consider, for example, the common reaction when we hear that a learner requires an accommodation to join the clinical team. In this context, an accommodation refers to workplace measures designed to support the trainee’s integration and success within the clinical team. Yet, within the CBE trajectory, bias often transforms this need into concerns: doubts about the learner’s ability to achieve competency, worries about time management, or fears of added strain on the team’s workflow. Unfortunately, we have not yet reached that stage in CBE where it is standard practice to ask both learners and colleagues what they need to succeed and thrive in their work and learning environments—and to recognize that those needs will be unique to each individual.
Consider a neurodiverse learner whose communication style has created conflict with peers, patients, and care partners. How do we navigate the intertwined competencies of communication, collaboration, and professionalism in such cases? Structurally, there are gaps in how we support these learners. Information about accommodations is often sparse, leaving learners to repeatedly explain their needs. Moreover, we rarely create environments that foster trust between learners and faculty. Coaching in clinical learning and workplaces is meant to be a central mechanism for achieving CBE, yet when faculty members serve simultaneously as assessors, supervisors, and coaches, role ambiguity arises. This overlap can create confusion, reduce clarity, and ultimately set the stage for mistrust in the learning and work environment.
The Analogy: The Halt Switch in CBE
So, using the Andon cord principle, how would we stop the CBE assembly line when we discover dysfunctions in the production line (i.e., the training process) of healthcare professionals (aka learners)? What would restarting the assembly line look like once the dysfunction has been rectified? A complexity in our CBE assembly line analogy is that the production of high-quality, high-functioning healthcare professionals is just one of many focus areas, or ‘sub’ assembly lines, of CBE. Ultimately, the goal of CBE is to provide and safeguard the health and well-being of patients, care partners, and communities. Another sub-assembly line builds high-functioning teams who provide quality care. These sub-assembly lines often operate concurrently or may intersect, adding layers of complexity. Consider the example where the supervisor/teacher takes over a procedure—this action stops the assembly line where the learner is leading the provision of care and restarts with the supervisor now leading the care process. The supervisor/teacher has to consider the assembly line of the patient and quality care as well as the sub-assembly lines for the production of the healthcare professional (the learner’s achievement of the procedural EPA) and ensuring team functioning. Focusing on the learner assembly line in the CBE context, this sub-assembly line has been halted, and repair of potential harm(s) is needed. The harm(s) that require correction can be multiple, and the application of quality improvement principles is nested. For example, if communication regarding the need to pause the care for change in care provider is done well, and this teaching-learning outcome is one of many expected outcomes, then the assembly line can restart fairly easily with minimal harm after a quick debrief. Consider, though, if communication was poor, and there was no expectation of the learner losing the opportunity to lead the care plan, then we can anticipate a higher degree of harm. From there what actions need to be taken – do we stop to provide feedback to the supervisor regarding poor communication or inadequate teaching-learning preparation? Alternatively, do we pause the learner assembly line to repair the learner-teacher relationship and ensure the learner has a sense of belonging and ensure learning, while the patient care line has continued to operate relatively smoothly? Does the overarching care assembly line and team sub-assembly line require a pause to repair the patient’s and team members’ lost trust that resulted when the learner was unable to complete the procedure? Both of these potential outcomes can further cause disruption to the learning assembly line in the moment, as well as downstream.
Lessons for the future
Looking forward, what will pulling the Andon cord mean for CBE and the various groups impacted? Our premise is that advocacy for self and others, autonomy, fairness, inclusion, and participation would be enhanced. Also, what will the process look like in practice? Pulling the cord can take many forms. At the individual and team levels, it would involve speaking up informally and formally. At the macro level, it would mean creating environments that facilitate all voices to be heard and engaged, thereby fostering participation. These actions enable autonomy and advocacy for self and others. For example, anyone can pull the cord regardless of power and privilege, and their feedback and input would be encouraged. Further inclusion occurs when environments are adapted such that everyone feels welcome and supported, and with mutual accountability, the trust grows among the group, leaders, and the system. Ultimately, achieving all these goals would promote relationship building and mutual trust. We believe that through this collective trust, co-creation in CBE can more readily occur, and change can be enacted through a continuous quality improvement lens. In this way, the dysfunctions of CBE can be addressed meaningfully and ensure a more just healthcare and health professions education system.es it stronger.
About the Author:
Jamiu O. Busari, MBChB, MD, MHPE, PhD, CCPE, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht. Dr. Busari is a consultant pediatrician and program director of pediatrics at Dr. Horacio Oduber Hospital in Aruba. He is an Associate Professor of medical education at Maastricht University and the founder of the Jump18 Foundation – Aruba Childhood Obesity Prevention and Intervention Program.
Ming-Ka Chan, MD, MHPE, FRCPC, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht. Dr. Chan is the Director, Office of Leadership Education, Rady Faculty of Health Services, and Professor of Pediatrics and Pediatrics Lead, Antiracism/Social Justice, University of Manitoba, Canada. She is a consultant pediatrician through programs organized under Jordan’s Principle working in Manto Sipi and Nisichawaysihk Cree Nations.
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