CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
ABOUT THE TRAINING PROGRAM :-
Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented.
DESIGNED FOR :-
Managers, Engineers, Supervisor and officers engaged in maintenance operation and engineering activities.
OBJECTIVE :-
At the end of the training program, participants will be able
- To gain a basic understanding of the problem solving and decision-making process and the applicable quality tools that support this process.
- To develop specific competencies to use the structured approach to problem solving and decision making and the supporting quality tools.
TRAINING PROGRAM COVERAGE :-
- Basic knowledge about RCA program.
- What are the RCA tools ?
- More about Why- Why analysis ?
- Videos and case studies on RCA
Root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. A factor is considered a root cause if removal thereof from the problem-fault-sequence prevents the final undesirable event from recurring; whereas a causal factor is one that affects an event's outcome, but is not a root cause. Though removing a causal factor can benefit an outcome, it does not prevent its recurrence with certainty.
RCA is a part of Problem Management and basic tool for Problem and Error Control.
This document should help you to understand Root Cause Analysis more closely
Enjoy learning
- Loved it ? Like it here and ask me for a copy :-)
CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
ABOUT THE TRAINING PROGRAM :-
Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. The practice of RCA is predicated on the belief that problems are best solved by attempting to address, correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is more probable that problem recurrence will be prevented.
DESIGNED FOR :-
Managers, Engineers, Supervisor and officers engaged in maintenance operation and engineering activities.
OBJECTIVE :-
At the end of the training program, participants will be able
- To gain a basic understanding of the problem solving and decision-making process and the applicable quality tools that support this process.
- To develop specific competencies to use the structured approach to problem solving and decision making and the supporting quality tools.
TRAINING PROGRAM COVERAGE :-
- Basic knowledge about RCA program.
- What are the RCA tools ?
- More about Why- Why analysis ?
- Videos and case studies on RCA
Root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. A factor is considered a root cause if removal thereof from the problem-fault-sequence prevents the final undesirable event from recurring; whereas a causal factor is one that affects an event's outcome, but is not a root cause. Though removing a causal factor can benefit an outcome, it does not prevent its recurrence with certainty.
RCA is a part of Problem Management and basic tool for Problem and Error Control.
This document should help you to understand Root Cause Analysis more closely
Enjoy learning
- Loved it ? Like it here and ask me for a copy :-)
Root Cause Analysis - methods and best practiceMedgate Inc.
A critical part of any safety management system comes after incidents occur. Effective incident investigation including root cause analysis can provide many answers for your organization regarding why an incident or event has occurred. Even if your safety department excels at completing investigations and undertaking corrective actions, your SMS will not be effective if you fail to identify root causes quickly and accurately.
Safety teams that make Root Cause Analysis central to their day-to-day activities will significantly improve their ability to better the safety of the workplace and ensure that incidents do no reoccur.
In these slides, Medgate Safety expert Shannon Crinklaw discusses Root Cause Analysis, outlining its potential impact, covering different analysis methodologies and outlining best practices.
To view the accompanying webinar, go to http://bit.ly/X518oY where you will learn:
What type of incidents are most common.
Mistakes that organizations should avoid when carrying out root cause analysis.
Different models of root cause analysis, such as Five Why and Cause-and-Effect diagrams.
The long term benefits of root cause analysis efforts.
Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root CauseCraig Thornton
This webinar discusses and investigates how to conduct root cause analysis. Root cause analysis is something that companies really struggle with. There will be plenty of practical advice in the webinar to help with you understand the concepts and the tools.
If you would like to watch the recording of this webinar then copy and paste the below link into your web browser:
http://www.mangolive.com/blog-mango/root-cause-analysis-tools-webinar
Root cause Analysis (RCA) & Corrective and Preventive action (CAPA) in MRCT d...Bhaswat Chakraborty
This presentation describes Identification & differentiation of Protocol deviation & violation; Different methods of RCA & best suitable method for Multiregional Clinical Trial; CAPA management and CAPA application to other trial sites/CRO/SMO/ Country that is involved in same trial (Strategic Management and application of CAPA in MRCT)
A structured approach to the investigation process should be used with the objective of determining the root cause.
The level of effort, formality, and documentation of the investigation should be commensurate with the level of risk, in line with ICH Q9.
Creating a culture of continuous improvement requires having an AIM or knowing exactly what the organization is striving for.
This means the entire organization should understand the concept of excellence and continually look for ways to do things better and more efficiently, resulting in higher levels of effectiveness.
When everyone understands the aim of excellence, there’s a synergy to achieve that objective. Excellence doesn’t just happen; it’s intentional!
To achieve excellence, you need a systematic approach to improvement initiatives that result in positive change for the organization.
A basic presentation that the describes the principles of RCA and focuses on the 5-whys method and how it can be utilized to solve our everyday incidents.
A sample of slides used in our FMEA Training for Healthcare. This 3-day class is ideal for quality facilitators with hospitals and health systems. The key deliverable is a preliminary FMEA on a high-risk process of the client's choosing, complete with an improvement plan.
Root cause analysis is an approach for identifying the underlying causes of an incident so that the most effective solutions can be identified and implemented.
The process of diagnosing product problems identified during design, manufacture or use brings many challenges. The presentation will discuss ways to alleviate these difficulties using a structured, troubleshooting-based approach, and being aware of some common errors and ways of dealing with them.
• How to analyze data for low frequency failures
• Using the information from RCA for improving both prevention and detection
• Understand why finding a product solution often isn’t enough
Root Cause Analysis - methods and best practiceMedgate Inc.
A critical part of any safety management system comes after incidents occur. Effective incident investigation including root cause analysis can provide many answers for your organization regarding why an incident or event has occurred. Even if your safety department excels at completing investigations and undertaking corrective actions, your SMS will not be effective if you fail to identify root causes quickly and accurately.
Safety teams that make Root Cause Analysis central to their day-to-day activities will significantly improve their ability to better the safety of the workplace and ensure that incidents do no reoccur.
In these slides, Medgate Safety expert Shannon Crinklaw discusses Root Cause Analysis, outlining its potential impact, covering different analysis methodologies and outlining best practices.
To view the accompanying webinar, go to http://bit.ly/X518oY where you will learn:
What type of incidents are most common.
Mistakes that organizations should avoid when carrying out root cause analysis.
Different models of root cause analysis, such as Five Why and Cause-and-Effect diagrams.
The long term benefits of root cause analysis efforts.
Root Cause Analysis - Tools, Tips and Tricks to Get to the Bottom of Root CauseCraig Thornton
This webinar discusses and investigates how to conduct root cause analysis. Root cause analysis is something that companies really struggle with. There will be plenty of practical advice in the webinar to help with you understand the concepts and the tools.
If you would like to watch the recording of this webinar then copy and paste the below link into your web browser:
http://www.mangolive.com/blog-mango/root-cause-analysis-tools-webinar
Root cause Analysis (RCA) & Corrective and Preventive action (CAPA) in MRCT d...Bhaswat Chakraborty
This presentation describes Identification & differentiation of Protocol deviation & violation; Different methods of RCA & best suitable method for Multiregional Clinical Trial; CAPA management and CAPA application to other trial sites/CRO/SMO/ Country that is involved in same trial (Strategic Management and application of CAPA in MRCT)
A structured approach to the investigation process should be used with the objective of determining the root cause.
The level of effort, formality, and documentation of the investigation should be commensurate with the level of risk, in line with ICH Q9.
Creating a culture of continuous improvement requires having an AIM or knowing exactly what the organization is striving for.
This means the entire organization should understand the concept of excellence and continually look for ways to do things better and more efficiently, resulting in higher levels of effectiveness.
When everyone understands the aim of excellence, there’s a synergy to achieve that objective. Excellence doesn’t just happen; it’s intentional!
To achieve excellence, you need a systematic approach to improvement initiatives that result in positive change for the organization.
A basic presentation that the describes the principles of RCA and focuses on the 5-whys method and how it can be utilized to solve our everyday incidents.
A sample of slides used in our FMEA Training for Healthcare. This 3-day class is ideal for quality facilitators with hospitals and health systems. The key deliverable is a preliminary FMEA on a high-risk process of the client's choosing, complete with an improvement plan.
Root cause analysis is an approach for identifying the underlying causes of an incident so that the most effective solutions can be identified and implemented.
The process of diagnosing product problems identified during design, manufacture or use brings many challenges. The presentation will discuss ways to alleviate these difficulties using a structured, troubleshooting-based approach, and being aware of some common errors and ways of dealing with them.
• How to analyze data for low frequency failures
• Using the information from RCA for improving both prevention and detection
• Understand why finding a product solution often isn’t enough
VMware’s Nathan Small who works as a Staff Engineer at Global Support Services has put together a great presentation about Advanced Root Cause Analysis. The presentation was designed to give you more insight into how a VMware Technical Support Engineer reviews logs, gathers data and performs in-depth analysis. Nathan is hoping to show you the skills they’re using every day to help determine the root cause for an issue in your environment. With this core knowledge, you will become more self-sufficient within your own environment and be able to diagnose an issue as it occurs rather than after the damage has been done.
Delayed discharges - A patient flow and safety imperativeAnn Marie O'Grady
Presentation details change project to improve patient flow and safety in Beaumont Hospital, Dublin, for patients whose discharge is delayed awaiting a residential nursing home bed
An introduction to SigmaXL Version 6.2. Includes installation notes and important information on recommended data format.
Established in 1998, SigmaXL Inc. is a leading provider of user friendly Excel Add-ins for Lean Six Sigma graphical and statistical tools and Monte Carlo simulation.
SigmaXL® customers include market leaders like Agilent, Diebold, FedEx, Microsoft, Motorola and Shell. SigmaXL® software is also used by numerous colleges, universities and government agencies.
Our flagship product, SigmaXL®, was designed from the ground up to be a cost-effective, powerful, but easy to use tool that enables users to measure, analyze, improve and control their service, transactional, and manufacturing processes. As an add-in to the already familiar Microsoft Excel, SigmaXL® is ideal for Lean Six Sigma training and application, or use in a college statistics course.
DiscoverSim™ enables you to quantify your risk through Monte Carlo simulation and minimize your risk with global optimization. Business decisions are often based on assumptions with a single point value estimate or an average, resulting in unexpected outcomes.
DiscoverSim™ allows you to model the uncertainty in your inputs so that you know what to expect in your outputs.
Root Cause Analysis – A Practice to Understanding and Control the Failure Man...inventionjournals
International Journal of Business and Management Invention (IJBMI) is an international journal intended for professionals and researchers in all fields of Business and Management. IJBMI publishes research articles and reviews within the whole field Business and Management, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
Corrective and Preventative Action (CAPA) is a system of quality procedures required to eliminate the causes of an existing nonconformity and to prevent recurrence of nonconforming product, processes, and other quality problems.
Operating Excellence is built on Corrective & Preventive ActionsAtanu Dhar
You see an issue and you simply set it right, but do you make the effort to find out what is the "corrective" action behind it, so that it never re-occurs?
And, do you take another extra step to come up with a "preventive" action - so that there is no other manner that issue comes up?
Cause and Effect Analysis is a technique for identifying all the possible causes (inputs) associated with a particular problem / effect (output) before narrowing down to the small number of main, root causes which need to be addressed.
HAZOP, or a Hazard and Operability Study, is a systematic way to identify possible hazards in a work process. In this approach, the process is broken down into steps, and every variation in work parameters is considered for each step, to see what could go wrong. HAZOP’s meticulous approach is commonly used with chemical production and piping systems, where miles of pipes and numerous containers can cause logistical headaches.
HAZOP and Hazard Analysis Systems
Handling of deviations in Quality Control / Quality Assurance for Pharmaceuticals API, FP Manufacturing. Regulatory and compliance in analytical laboratory
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
3. ROOT CAUSE ANALYSIS
Is a process done in response to
occurrence of sentinel event or near
miss.
The aim of root cause analysis is to
conduct intensive analysis to reach the
embedded problems in the system and
solve it.
4. RCA- SEQUENTIAL STEPS
1- Define the problem
Ask what is wrong, what is involved: conditions, activities,
materials.
Ask when: day ,date, time, shift, time pattern, schedule.
Ask where: site, area department, physical environment, step
in process.
Ask how the what or who is affected, how much, how many,
work practice, omission / commission.
Ask who is involved: patients, caregivers, other staff, vendors,
visitors.
Review relevant documents.
Consider other data collection options: surveys, observations,
interviews.
5. RCA- SEQUENTIAL STEPS
2- perform task / process analysis
divide a process into steps by sequencing actions,
instructions, conditions ,tools , and materials associated
with the performance of the task (flowchart).
learn exactly what was supposed to happen.
contrast the baseline with what actually happened (based
on initial data collection).
6. RCA- SEQUENTIAL STEPS
3- perform change /different analysis:
compare the task /steps successfully performed to
the same task /steps when unsuccessful.
analyze the difference.
describe for each difference its effect on the
situation.
7. RCA- SEQUENTIAL STEPS
4- perform control barriers/ safe guard analysis:
analyze safeguards needed to prevent the event.
analyze missing or ineffective safeguards.
Safeguards may be :
physical: safety equipment and devices; locks, walls.
Natural: distance and time (limited exposure).
information: caution such as labels , alarms.
knowledge: making information constantly available.
administrative: safety policies and procedures,
regulations, supervisory practices, training, education,
communication process.
8. RCA- SEQUENTIAL STEPS
5- Begin cause and effect analysis
List each undesirable step of the occurrence
considering each a primary effect
using data collected to date , determine what
causes allowed or forced each effect to occur
show the relationship between each cause and
effect
9. RCA- SEQUENTIAL STEPS
continue the cause and effect analysis until :
Cause is outside the organization control to
correct.
Primary effect is fully explained.
No other causes can be found to explain the
effect.
Further analysis will yield no additional benefit
in correcting the problem.
List all validated causes.
11. FLOWCHART
Definition: A flowchart is a pictorial
representation displaying the:
Actual sequence of steps and their inter-
relationships in a specific process in
order to identify hand-off (appropriate
and inappropriate), inefficiencies,
redundancies, inspections, and waiting
steps; and/or
Ideal sequence of steps, once the actual
process is known.
12. Symbols Used in Flowcharts
Start / End
Process Step
Decision
Connector
No
Yes
A
13.
14. FLOWCHART
Use when:
Identifying and describing a current
process
Questioning whether there is a process
Questioning whether actual process
meets current policy/procedure
Analyzing problems to determine causes
Redesigning the process as part of the
action
Designing a new process
15. FLOWCHART
Steps:
Determine the boundaries (the start and
stop points) of the process under review.
Brainstorm to identify all activities and
decision points in the process;
Place all activities and decision points in
sequence.
Cont..
16. FLOWCHART
Design the flowchart, placing:
each activity in a box (square or rectangle)
each decision in a diamond,
ovals or circles for the start and stop points,
connecting arrows indicating the flow.
If there is more than one "output" arrow from an activity box,
it probably requires a decision diamond;
Cont...
17. FLOWCHART
Analyze the flowchart, looking for process
"glitches": inefficiencies, omissions/gaps,
redundancies, barriers, etc.
Also look for the smooth parts of the process to
use as models or "best practices" for
improvement;
Decide whether to correct steps within the
current process, design a new process, or do
corrections first, then redesign in the future.
18. INTERPRETING A FLOWCHART
Step 1 - Examine each process step
Bottlenecks? Poorly defined steps?
Ineffective sequence? Delays?
Weak links?
Step 2 - Examine each decision symbol
Can this step be eliminated?
Step 3 - Examine each rework loop
Can it be shortened or eliminated?
Step 4 - Examine each activity symbol
Does the step add value for the end-
user?
19. Fire Drill Preparation Flowchart
A
Yes No
Yes
No
Yes
No
NoYesYes
No
Yes
NoFirst drill
in set?
A
Inform the drill
leader and improvise
Props?
Search
Torpedo Room
Radios
still not
available
?
Borrow from
Quartermasters
Check with
Radiomen
Radios
available?
Props
available?
Enough
red hats?
Drill monitors
test the radios
Monitors go to Logroom to get red
hats, radios, and drill props
Complete the
Drill Brief
Drill monitors
take station
Search the
boat for
red hats
No
No
Yes
Yes
Discrepancy?
All
personnel
on station
?
Correct it
Put simulation
on the
appropriate
gages
Drill leaders walk
around to ensure
all monitors are
on station
Spot check safety
intervention points
Order initial
conditions set
Find them
and put them
on station
22. CAUSE-AND-EFFECT DIAGRAM
Definition: The cause-and-effect diagram is a
tool generally used to gather all possible
causes as an overview,
The ultimate goal being to uncover the root
cause(es) of a problem.
The specific problem is usually stated as a
negative outcome ("effect") of a process, e.g.,
late transfer of patients from the inpatient
facility to skilled nursing facilities.
23. CAUSE-AND-EFFECT DIAGRAM
The diagram is a visualization of relationships
between the outcome of a particular system or
process, the major categories of that system or
process (the main branches), and causes and
subcauses (sub-branches off main branches).
Steps
Start with the outcome (problem statement) on
the right of the paper, halfway down; draw a
horizontal line across the middle of the paper
with an arrow pointing to the outcome;
24. CAUSE-AND-EFFECT DIAGRAM
Determine and define the major categories
which describe the system or process under
review, e.g.,
5ps: (or) 5ms:
People Manpower
Provisions Materials
Policies Machines
Procedures Methods
Place Measurements
25. BASIC LAYOUT OF
CAUSE AND EFFECT DIAGRAMS
EFFECT
Manpower
(People)
Methods
(Procedures)
Materials
(Policies)
Machines
(Plant)
Environment
26. CAUSE-AND-EFFECT DIAGRAM
Link the major categories (representing
process and structure) to the outcome with
diagonal lines angled from the horizontal
line away from the outcome;
Brainstorm to identify possible main causes
of the negative outcome and link each to
one of the major categories, using
horizontal lines (parallel to the main
outcome line) touching the appropriate
diagonal line;
27. CAUSE-AND-EFFECT DIAGRAM
Identify any possible sub-causes of main
causes by using the "Five-Why" technique.
Evaluate the draft diagram as a team to
determine the accuracy of the placement of
issues and lines;
28. CAUSE-AND-EFFECT DIAGRAM
Once the diagram seems appropriate to the
team, further evaluate for:
Obvious improvement options;
Causes already resolved or eliminated;
Causes easily resolved or eliminated;
Issues raised which require more in-depth
assessment to be understood.
29. CAUSE & EFFECT EXAMPLE MJII p. 29
Bed Assignment Delay
Information provided courtesy of
Rush-Presbyterian-St. Luke’s Medical Center
System incorrect
Machine (PCIS)Timing
Hospital procedures Communication
Patient waits
for bed
Not entered
Not used
No trust
Need more training
Functions not useful
Not used
pending discharge
Discharged patient
did not leave
Wait for results
Wait for lunch
Wait for ride
Call housekeeping
too late
Wait for MD
Call housekeeping
too early
Think it will take
more time
Patient arrives
too early
Transfer too early
from another hospital
Call housekeeping
when clean
Nursing shortage
Unit clerk staffing
Unit clerk training
Resources
Unit clerk unaware
of discharge or transfer
On break
Not told
Shift change
Reservation
unaware
Not entered
Unit switch bedAdmitting unaware
bed is clean
Delayed
entry
Sandbag
Too busy
Inappropriate
ER admittance
Many
transfers
Specialty beds
Cardiac monitors
Double rooms
Physician did
not write order
Medicine
admit quota
Physician misuse –
inpatient
MD procedures
30.
31. THE FIVE WHYS
What is it?
A tool to help uncover the root
cause or real reason for the issue
It is a variation of the approach
used in fishbone analysis
When would you use it?
When you have identified an issue
and want to deepen your
understanding of it and its
underlying causes
It avoids group moving into ‘fix it’
mode and addressing the
symptoms of an issue without
understanding the root causes
Issue
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why …
32. PROCESS OF FIVE WHYS
• Clearly define the issue to be tackled and write it on the left
side of the paper
• Complete the diagram by moving from left to right. Move from
the problem/issue statement by asking the question “why?”
• Ask the group “why?” and capture the responses
• For each response, again ask the question “why?”. Continue to
record responses and move across to the right of the diagram.
Try to go to five levels of “why?”
• At the end of the analysis it is often helpful to circle the most
significant insights that have been gained
33. FIVE WHYS – EXAMPLE
Revenue budget
not
balanced
Costs too high
Income too low
Premises costs 8.5%
Staffing costs 86% of
the budget.
Income heavily
reliant on LEA
formula.
Schools facilities are
underused
Teachers used to support pupils with SEN.
Large number of management points
Staffing very stable
Historic.
Have allowed some queue jumping.
Cleaners local people with strong
connection to school.
Employ own cleaning staff at high rates.
Plan still has 3 years to run.
Roll drop in January
Coordinator’s salary now in main school budget.
School decided not to reapply 2 years ago.
Knock-on impact in other areas e.g. FSM, SEN
Health and safety issues.
LEA cut back on community use of school.
Greater variety of facilities available.
Governing body have stopped s/keeper overtime.
Premises staff costs
3.5%
Low number of TAs
Teachers are 70%
5 year routine
maintenance plan
undercosted.
New Council sports centre
opened locally
LEA uses January PLASC
for Fair Funding formula.
Beacon school funding
not renewed
School not used for
external events.
34. KEPNET-TREGOE (IS-IS NOT) MATRIX
Purpose : Isolate and Identify causes of quality problems
by assisting managers in recognizing factors that
underlie defects in a process.
Advantages
Relates possible causes to specific categories
Identifies process problems
Simplifies development of ways to resolve the problems
35. KEPNET-TREGOE (IS-IS NOT) MATRIX
Creation Steps
Characterize the problem
Easily understood by QI team
Create agreement on the nature of the predicament
Create the Is-Is Not Matrix
Who is involved in the process or problem? (No blame game)
What inputs or outputs are involved in the process or problem?
When does the problem occur? In what portion of the process?
Where does the problem occur? In what part of the organization or
what location?
How important is the problem to the process? How extensive is the
problem?
QI Team formulates entries for each cell
Emerging patterns identify deficiencies in the process
36. KEPNET-TREGOE (IS-IS NOT) MATRIX
Is (
PROCESS)
Is not ( problem)
Who is involved in the process or
problem
What inputs or outputs are
involved in the process or problem
When does the problem occur? In
what portion of the process
Where does the problem occur? In
what part of the organization or
what location?
How important is the problem to
the process? How extensive is the
problem?
39. BRAINSTORMING
Definition: Brainstorming is a structured group
process used to create as many ideas as
possible in as short a time as possible, e.g.,
one session, and to elicit both individual and
group creativity.
Structured Brainstorming: Everyone in the
group gives an idea in rotation or passes until
the next round.
Unstructured Brainstorming: Everyone in the
group gives ideas as they come to mind.
40. EXPERIMENTS HAVE SHOWN---
BRAINSTORMING WILL
TYPICALLY GENERATE THREE TIMES
THE QUANTITY OF IDEAS THAN THAT
GENERATED BY THE SAME INDIVIDUAL
WORKING SEPERATELY
41. BRAINSTORMING
Lists generated may relate to:
Problems or topics
Components of a process
Indicators, criteria, elements for data
collection
Possible solutions Structure
42. RULES
1. PEOPLE MUST FEEL SAFE TO
PARTICIPATE
2. DURING BRAINSTORMING---
NO JUDGEMENT
NO CRITICISM
3. GENERATE AS MANY IDEAS AS
POSSIBLE
4. ENCOURAGE TO BE CREATIVE
5. BUILD ON EACH OTHER’S IDEAS
6. WRITE DOWN EXACTLY WHAT IS SAID
DO NOT DISCUSS IDEAS
43. FIVE STEPS OF BRAINSTORMING
Define the subject and direction of the session;
Allow time for initial, individual thought;
Establish a time limit for the entire session;
Request ideas according to the predetermined
structure; keep circling the issue until all ideas
are recorded
Clarify all ideas generated to assure accuracy
and understanding.
44. ADVANTAGES
1. ENCOURAGES CREATIVE THINKING
2. HELPS TO IDENTIFY
=POSSIBLE CAUSES
=AREAS FOR IMPROVEMENT
=POSSIBLE SOLUTIONS
3. ALLOWS FOR DIFFERENT POINTS
OF VIEW
4. ENCOURAGES PARTICIPATION
45. AFFINITY DIAGRAM
Definition: An affinity diagram is an organizational
tool most often used at the beginning of a team's
work to organize large volumes of ideas or issues
into major categories.
The ideas may have come from the group's initial
brainstorming session.
46. AFFINITY DIAGRAM
"Affinity" means close relationship or
connection, or similarity of structure;
When developing an Affinity Diagram, it is
most important to determine the primary
issue and major related subgroups in order
to grasp the appropriate relationships, links,
or connections.
47. AFFINITY DIAGRAM
Steps:
Define the primary issue, using neutral, broad
language;
Brainstorm - use cards or adhesive notes which
can be moved and sorted;
Display in random fashion all ideas for the team
(on a wall or table);
Cont..
48. AFFINITY DIAGRAM
Each team member participates in sorting the
ideas into major groupings -- in silence and
quickly, without discussion and without time for
contemplation -- until team consensus is reached;
Discuss the major groupings and create a concise
title for each grouping;
Draw the affinity diagram, based on major
groupings, linking all ideas related to each
grouping.
49. AFFINITY DIAGRAM
Each team member participates in sorting the
ideas into major groupings -- in silence and
quickly, without discussion and without time for
contemplation -- until team consensus is reached;
Discuss the major groupings and create a concise
title for each grouping;
Draw the affinity diagram, based on major
groupings, linking all ideas related to each
grouping.
50. DISPLAY THE GENERATED IDEAS
ISSUES IN IMPLEMENTING CONTINUOUS PROCESS IMPROVEMENT
Behavior
modifications may
take longer than
time available Too many
projects at once
Everybody
needs to change
but me
Data collection
process needs
Need new data
collection
system
Developing
product without
developing
process
Too busy to
learn Don’t know what
customer wants
Short-term
planning mentality
Pressure for
success
Lack of training at
all levels
Lack of
management
understanding of
need for it
Competition
versus
cooperation
Need to be
creative
Some people will
never change
What are the
rewards for using
tools
Lack of follow-
up by
management
Unrealistic
allotment of
time
Lack of trust in
the process
Not using
collected
data
Which comes first,
composing the
team or stating the
problem?
Want to solve
problem before
clearly defined
51. Sort Ideas into Related Groups
Issues in Implementing Continuous Process Improvement
Want to solve
problem before
clearly defined
Too many
projects at once
Data collection
process needs
Need new data
collection
system
Developing
product without
developing
process
Too busy to
learn
Don’t know what
customer wants
Behavior
modifications may
take longer than
time available
Pressure for
success
Short-term
planning mentality
Lack of
management
understanding of
need for it
Lack of training
at all levels
Need to be
creative
Competition
versus
cooperation
Some people
will never
change
What are the
rewards for using
tools
Lack of follow-
up by
management
Unrealistic
allotment of
time
Lack of trust in
the process
Not using
collected
data
Which comes first,
composing the team
or stating the
problem?
Everybody needs
to change but me
52. Create Header Cards
Issues in Implementing Continuous Process
Improvement
(Header Cards)
Breaking through
old way
“Dinosaur”
thinking
Lack of
planning
Organizational
issues
Old
managemen
t culture
Lack of
TQL
knowledge
53. Finished Affinity Diagram
Issues in Implementing Continuous Process Improvement
Breaking through
old way
“Dinosaur”
thinking
Lack of
planning
Organizational
issues
Old
management
culture
Lack of TQL
knowledge
Want to solve
problem before
clearly defined
Too many
projects at once
Everybody
needs to change
but me
Data collection
process needs
Need new data
collection
system
Developing product
without developing
process
Too busy to
learn
Don’t know what
customer wants
Behavior
modifications may
take longer than
time available
Pressure for
success
Short-term
planning mentality
Lack of
management
understanding of
need for it
Lack of training at
all levels
Need to be
creative
Competition
versus
cooperation
Some people will
never change
What are the
rewards for using
tools
Lack of follow-up
by management
Unrealistic
allotment of
time
Lack of trust in
the process
Not using
collected
data
Which comes first,
composing the team
or stating the
problem?
55. MULTI-VOTING
A repetitive process used by a team to select the most
important or popular items from a large list of items
generated by the team
Benefits of Multi-voting
• Reduces a larger list of items.
• Prioritizes team issues.
• Identifies important items.
56. PROCEDURES FOR MULTI-VOTING
Step 1 - Work from a large list
Step 2 - Assign a letter to each item
Step 3 - Tally the votes
Step 5 - Repeat the process
57. MULTI-VOTING EXAMPLE
LACK OF MEETING PRODUCTIVITY
FIRST VOTE TALLY
| A. No agenda | I. Problems not mentioned
|||| B. No clear objectives |||| J. Interrupted by
phone calls
|| C. Going off on tangents || K. Few meaningful metrics
| D. Extraneous topics |||| L. Interrupted by visitors
|| E. Too many "sea stories" ||| M. No administrative support
|||| | F. Vital members missing |||| N. Meetings extended
from meeting beyond allotted time
|||| G. Not enough preparation |||| O. Members distracted by
for meetings pressing operations
|||| H.Unclear charts
58. MULTIVOTING EXAMPLE
LACK OF MEETING PRODUCTIVITY
SECOND VOTE TALLY
B. No clear objectives
F. Vital members missing from meeting
G. Not enough preparation for meetings
J. Interrupted by phone calls
L. Interrupted by visitors
N. Meetings extended beyond allotted time
O. Members distracted by pressing operations
59. PRIORITIZATION MATRIX
Definition: A Prioritization matrix is a tool used
to select one option from a group of
alternatives, be they problems or solutions.
It promotes objective decision making.
60. PRIORITIZATION MATRIX
Steps:
1. Limit the list of options (of problems or solutions)
to no more than eight (8);
2. Select the criteria against which each option will
be rated, stated in either positive or negative
terms, but not both;
3. Determine the weight (relative value) of each
criterion; perhaps some are more important to
meet than others;
Cont..
61. PRIORITIZATION MATRIX
4. Select a scoring method, e.g.:
Point system:
From 5 = Very important To 0 = Unimportant
Yes/No system: Criteria Met? Y n Yes; N =
No
Check mark: Box checked if criteria
met
+ or - system:
+ = Important/criteria met
- = Unimportant/criteria not met
66. ACTION PLANNING
Once the team selects a solution, an action plan need to
be developed.
Action plans at a minimum identifies:
what to be done? (deliverables)
How a certain task will be done?( implementation Strategies)
who will do it?( R)
Time Frame
A mean of verification that a certain task has been done
The team leader is responsible of monitoring the
implementation process.
67. CASE STUDY
MS. MARTINEZ, JANUARY 2000
Ms. Martinez, a divorced working mother in her early
50s with two children in junior high school, was new in
town and had to choose an insurance plan.
She had difficulty knowing which plan to select for her
family, but she chose City-Care because its cost was
comparable to that of other options, and it had
pediatric as well as adult practices nearby.
68. Once she had joined CityCare, she was asked to
choose a primary care physician. After receiving
some recommendations from a neighbor and
several coworkers, she called several of the offices
to sign up. The first two she called were not
accepting new patients. She finally found one.
69. Juggling repairs on their new apartment, finding the best
route to work, getting the children’s immunization records
sent by mail, and making other arrangements to get them
into a new school, Ms. Martinez delayed calling her new
doctor’s office for several months. When she called for an
appointment, she was told that the first available non
urgent appointment was in 2 months; she hoped she
would not run out of her blood pressure medication in the
interim.
70. When she went for her first appointment, she was
asked to complete a patient history form in the waiting
room. She had difficulty remembering dates and
significant past events and doses of her medications.
After waiting for an hour, she met with Dr. McGonagle
and had a physical exam. Although her breast exam
appeared to be normal, Dr. McGonagle noted that she
was due for a mammogram.
71. Ms. Martinez called a site listed in her provider
directory and was given an appointment for a
mammogram in 6 weeks. The staff suggested that
she arrange to have her old films mailed to her.
Somehow, the films were never sent, and distracted
by other concerns, she forgot to follow up.
72. A week after the mammogram, she received a call
from Dr. McGonagle’s office notifying her of an
abnormal finding and saying that she should make an
appointment with a surgeon for a biopsy.
The first opening with the surgeon was 9 weeks later.
By now, she was very anxious. She hated even to
think about having cancer in her body, especially
because an older sister had died of the disease.
73. For weeks she did not sleep, wondering what would
happen to her children if she were debilitated or to
her job if she had to have surgery and lengthy
treatment. She was reluctant to call her mother,
who was likely to imagine the worst, and did not
know her new coworkers well enough to confide in
them.
74. After numerous calls, she was finally able to track
down her old mammograms. It turned out that a
possible abnormal finding had been circled the
previous year, but neither she nor her primary care
physician had ever been notified.
75. Finally, Ms. Martinez had her appointment with the
surgeon, and his office scheduled her for a biopsy.
The biopsy showed that she had a fairly unusual
form of cancer, and there was concern that it might
have spread to her lymph nodes.
76. She felt terrified, angry, sad, and helpless all at
once, but needed to decide what kind of surgery to
have. It was a difficult decision because only one
small trial comparing lumpectomy and mastectomy
for this type of breast cancer had been conducted.
She finally decided on a mastectomy.
77. Before she could have surgery, Ms. Martinez needed
to have bone and abdominal scans to rule out
metastases to her bones or liver. When she arrived at
the hospital for surgery, however, some of this
important laboratory information was missing. The
staff called and hours later finally tracked down the
results of her scans, but for a while it looked as though
she would have to reschedule the surgery.
78. During her mastectomy, several positive lymph nodes
were found. This meant she had to see the surgeon,
an oncologist, and a radiologist, as well as her primary
care physician, to decide on the next steps.
At last it was decided that she would have radiation
therapy and chemotherapy. She was given the phone
number for the American Cancer Society.
79. Before 6 months had gone by, Ms. Martinez found
another lump, this time under her arm. Cancer had
spread to her lung as well.
She was given more radiation, then more
chemotherapy.
Unfortunately, the condition worsened steadily and
cancer had spread leading to her death.
80. With your team conduct a root cause analysis for this
case.