SPC Handbook for the Treated Wood Industries
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Root Cause Analysis in Context of WHO International Classification for Patient Safety
Root cause analysis in context of WHO International Classification for Patient Safety Dr David Cousins Associate Director Safe Medication Practice and Medical Devices 1 NHS | Presentation to [XXXX Company] | [Type Date] How heath care provider organisations manage patient safety incidents Incident External organisation Healthcare Patient/Carer or agency professional Department of Health Incident report Complaint Regulators Health & Safety Request Risk/complaint Request additional manager additional Healthcare information information commissioners and purchasers Local analysis and learning Industry Feed back External report Root Cause AnalysisWhy RCA? (RCA) To identify the root causes and key learning from serious incidents and use this information to significantly reduce the likelihood of future harm to patients Objectives To establish the facts i.e. what happened (effect), to whom, when, where, how and why To establish whether failings occurred in care or treatment To look for improvements rather than to apportion blame To establish how recurrence may be reduced or eliminated To formulate recommendations and an action plan To provide a report and record of the investigation process & outcome To provide a means of sharing learning from the incident To identify routes of sharing learning from the incident Basic elements of RCA WHAT HOW it WHY it happened happened happened Human Contributory Unsafe Acts Behaviour Factors Direct Care Delivery Problems – unsafe acts or omissions by staff Service Delivery Problems – unsafe systems, procedures -
Guidance for Performing Root Cause Analysis (RCA) with Pips
Guidance for Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs) Overview: RCA is a structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process provides you with a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events. The purpose of an RCA is to find out what happened, why it happened, and determine what changes need to be made. It can be an early step in a PIP, helping to identify what needs to be changed to improve performance. Once you have identified what changes need to be made, the steps you will follow are those you would use in any type of PIP. Note there are a number of tools you can use to perform RCA, described below. Directions: Use this guide to walk through a Root Cause Analysis (RCA) to investigate events in your facility (e.g., adverse event, incident, near miss, complaint). Facilities accredited by the Joint Commission or in states with regulations governing completion of RCAs should refer to those requirements to be sure all necessary steps are followed. Below is a quick overview of the steps a PIP team might use to conduct RCA. Steps Explanation 1. Identify the event to be Events and issues can come from many sources (e.g., incident report, investigated and gather risk management referral, resident or family complaint, health preliminary information department citation). The facility should have a process for selecting events that will undergo an RCA. -
Root Cause Analysis in Surgical Site Infections (Ssis) 1Mashood Ahmed, 2Mohd
International Journal of Pharmaceutical Science Invention ISSN (Online): 2319 – 6718, ISSN (Print): 2319 – 670X www.ijpsi.org Volume 1 Issue 1 ‖‖ December. 2012 ‖‖ PP.11-15 Root cause analysis in surgical site infections (SSIs) 1Mashood Ahmed, 2Mohd. Shahimi Mustapha, 3 4 Mohd. Gousuddin, Ms. Sandeep kaur 1Mashood Ahmed Shah (Master of Medical Laboratory Technology, Lecturer, Faculty of Pharmacy, Lincoln University College, Malaysia) 2Prof.Dr.Mohd. Shahimi Mustapha,(Dean, Faculty of Pharmacy, Lincoln University College, Malaysia) 3Mohd.Gousuddin, Master of Pharmacy (Lecturer, Faculty of Pharmacy, Lincoln University College, Malaysia) 4Sandeep kaur,(Student of Infection Prevention and control, Wairiki Institute of Technology, School of Nursing and Health Studies, Rotorua: NZ ) ABSTRACT: Surgical site infections (SSIs) are wound infections that usually occur within 30 days after invasive procedures. The development of infections at surgical incision site leads to extend of infection to adjacent tissues and structures.Wound infections are the most common infections in surgical patients, about 38% of all surgical patients will develop a SSI.The studies show that among post-surgical procedures, there is an increased risk of acquiring a nosocomial infection.Root cause analysis is a method used to investigate and analyze a serious event to identify causes and contributing factors, and to recommend actions to prevent a recurrence including clinical as well as administrative review. It is particularly useful for improving patient safety systems. The risk management process is done for any given scenario in three steps: perioperative condition, during operation and post-operative condition. Based upon the extensive searches in several biomedical science journals and web-based reports, we discussed the updated facts and phenomena related to the surgical site infections (SSIs) with emphasis on the root causes and various preventive measures of surgical site infections in this review. -
Root Cause Analysis: the Essential Ingredient Las Vegas IIA Chapter February 22, 2018 Agenda • Overview
Root Cause Analysis: The Essential Ingredient Las Vegas IIA Chapter February 22, 2018 Agenda • Overview . Concept . Guidance . Required Skills . Level of Effort . RCA Process . Benefits . Considerations • Planning . Information Gathering • Fieldwork . RCA Tools and Techniques • Reporting . 5 C’s Screen 2 of 65 OVERVIEW Root Cause Analysis (RCA) A root cause is the most reasonably identified basic causal factor or factors, which, when corrected or removed, will prevent (or significantly reduce) the recurrence of a situation, such as an error in performing a procedure. It is also the earliest point where you can take action that will reduce the chance of the incident happening. RCA is an objective, structured approach employed to identify the most likely underlying causes of a problem or undesired events within an organization. Screen 4 of 65 IPPF Standards, Implementation Guide, and Additional Guidance IIA guidance includes: • Standard 2320 – Analysis and Evaluation • Implementation Guide: Standard 2320 – Analysis and Evaluation Additional guidance includes: • PCAOB Initiatives to Improve Audit Quality – Root Cause Analysis, Audit Quality Indicators, and Quality Control Standards Screen 5 of 65 Required Auditor Skills for RCA Collaboration Critical Thinking Creative Problem Solving Communication Business Acumen Screen 6 of 65 Level of Effort The resources spent on RCA should be commensurate with the impact of the issue or potential future issues and risks. Screen 7 of 65 Steps for Performing RCA 04 02 Formulate and implement Identify the corrective actions contributing to eliminate the factors. root cause(s). 01 03 Define the Identify the root problem. cause(s). Screen 8 of 65 Steps for Performing RCA Risk Assessment Root Cause Analysis 1. -
A New Non-Parametric Process Capability Index
A New Non-parametric Process Capability Index Deovrat Kakde Arin Chaudhuri Diana Shaw SAS Institute Inc. SAS Institute Inc. SAS Institute Inc. SAS Campus Dr., SAS Campus Dr., SAS Campus Dr., Cary, NC 27513, USA Cary, NC 27513, USA Cary, NC 27513, USA Email: [email protected] Email: [email protected] Email: [email protected] Abstract—Process capability index (PCI) is a commonly used Often manufacturing processes are not centered at the mid- statistic to measure ability of a process to operate within the given point of tolerance band. For such processes, PCI Cpk is specifications or to produce products which meet the required recommended. For a process centered at tolerance midpoint quality specifications. PCI can be univariate or multivariate depending upon the number of process specifications or qual- value, Cp and Cpk are identical. ity characteristics of interest. Most PCIs make distributional Many manufacturing processes have two or more corre- assumptions which are often unrealistic in practice. lated parameters of interest, which need to be monitored and This paper proposes a new multivariate non-parametric pro- controlled. For such processes, multivariate PCI are used. An cess capability index. This index can be used when distribution of excellent overview of various multivariate process capability the process or quality parameters is either unknown or does not follow commonly used distributions such as multivariate normal. indexes is provided in [19]. One of the popular parametric multivariate PCI is the multivariate capability vector (abbrevi- I. INTRODUCTION ated as MPCI) [12], [15]. This vector has three components. The first two components are computed with an assumption A process capability index (PCI) is an objective measure that the process data follows a multivariate normal distribution. -
Application of Monte Carlo Technique for Analysis of Tolerance & Allocation of Reciprocating Compressor Assembly 1Somvir Arya, 2Sachin Kumar, 3Viney Jain 1Dept
ISSN : 2249-5762 (Online) | ISSN : 2249-5770 (Print) IJRMET VOL . 2, ISSU E 1, AP ri L 2012 Application of Monte Carlo Technique for Analysis of Tolerance & Allocation of Reciprocating Compressor Assembly 1Somvir Arya, 2Sachin Kumar, 3Viney Jain 1Dept. of IIET, Mech. Engg., Kinana, Jind, Haryana, India ²Dept. of IIET, Electrical. Engg., Kinana, JInd, Haryana, India 3ACE & AR, Mithapur, Ambala, Haryana, India Abstract In order for mating feature (faces) of parts to fit together and The variation in part dimensions is one of the main causes of operate properly, each part must be manufactured within these variation in product quality. The allowable range in which the limits. The key, gears on the shaft, and other similar members dimension can vary is called tolerance. Tolerance can be expressed mounted by press or shrink-fit are toleranced so that the desired in either of two ways, 1). Bilatera 2). Unilateral tolerance. In interference is maintained without being so large as to make the bilateral tolerance, it is specified as plus or minus deviation from assembly impossible or the resulting stress too high. Tolerancing the basic size. In unilateral tolerance, variation is permitted only in is essential element of mass production and interchangeable one side direction from the basic size. If a part size and shape are not manufacturing, by which parts can be made in widely separated within tolerance limit, the part is not acceptable. The assignment location and then brought together for assembly. Tolerancing of actual values to the tolerance limits has major influence on makes it also possible for spare parts to replace broken or worn the overall cost and quality of an assembly or product. -
Statistical Process Control Tools: a Practical Guide for Jordanian Industrial Organizations
Volume 4, Number 6, December 2010 ISSN 1995-6665 JJMIE Pages 693 - 700 Jordan Journal of Mechanical and Industrial Engineering www.jjmie.hu.edu.jo Statistical Process Control Tools: A Practical guide for Jordanian Industrial Organizations Rami Hikmat Fouad*, Adnan Mukattash Department of Industrial Engineering, Hashemite University, Jordan. Abstract The general aim of this paper is to identify the key ingredients for successful quality management in any industrial organization. Moreover, to illustrate how is it important to realize the intergradations between Statistical Process Control (SPC) is seven tools (Pareto Diagram, Cause and Effect Diagram, Check Sheets, Process Flow Diagram, Scatter Diagram, Histogram and Control Charts), and how to effectively implement and to earn the full strength of these tools. A case study has been carried out to monitor real life data in a Jordanian manufacturing company that specialized in producing steel. Flow process chart was constructed, Check Sheets were designed, Pareto Diagram, scatter diagrams, Histograms was used. The vital few problems were identified; it was found that the steel tensile strength is the vital few problem and account for 72% of the total results of the problems. The principal aim of the project is to train quality team on how to held an effective Brainstorming session and exploit these data in cause and effect diagram construction. The major causes of nonconformities and root causes of the quality problems were specified, and possible remedies were proposed. © 2010 Jordan Journal of Mechanical and Industrial Engineering. All rights reserved Keywords: Statistical Process Control, Check sheets, Process Flow Diagram, Pareto Diagram, Histogram, Scatter Diagram, Control Charts, Brainstorming, and Cause and Effect Diagram. -
Tyson Foods Presentation Template
2019 Meat Industry Food Safety Conference Chicago, IL September 4, 2019 A Practitioner’s Reflections on SQC & SPC A Practitioner’s Reflections - On The Use Of SPC/SQC Techniques; or, How much education does a microbiologist, straight out of college, have on the application of SPC/SQC in a manufacturing environment? A Practitioner’s Reflections - On The Use Of SPC/SQC Techniques; or more specifically, why: - Is USDA tagging up my hotdogs? - Are customers complaining? - Is there is so much rework? - Am I addressing the same problem over and over? Statistical Quality Control (SQC) Statistical quality control (SQC) is defined as the application of the 14 statistical and analytical tools (7-QC and 7-SUPP) to monitor process outputs (dependent variables). Statistical Process Control (SPC) Statistical process control (SPC) is the application of the same 14 tools to control process inputs (independent variables). Although both terms are often used interchangeably, statistical quality control includes acceptance sampling where statistical process control does not. ASQ.ORG (2019) 4 SPC SQC Inputs Outputs Raw materials Finished product (lot) Process steps Manufacturer Customer / Consumer Establishment USDA/FSIS, FDA Raw Materials Step 1 Finished Product Step 2 Step # 5 Frederick W. Taylor Promoted “scientific management” principles to significantly increase economic productivity in the factory, by closely observing a production process and then simplifying the process into specific, individualized tasks. Utilizing time and sequential motion studies, -
System Performance and Process Capability in Additive Manufacturing: Quality Control for Polymer Jetting
polymers Article System Performance and Process Capability in Additive Manufacturing: Quality Control for Polymer Jetting Razvan Udroiu * and Ion Cristian Braga Department of Manufacturing Engineering, Transilvania University of Brasov, 29 Eroilor Boulevard, 500036 Brasov, Romania; [email protected] * Correspondence: [email protected]; Tel.: +40-268-421-318 Received: 19 May 2020; Accepted: 3 June 2020; Published: 4 June 2020 Abstract: Polymer-based additive manufacturing (AM) gathers a great deal of interest with regard to standardization and implementation in mass production. A new methodology for the system and process capabilities analysis in additive manufacturing, using statistical quality tools for production management, is proposed. A large sample of small specimens of circular shape was manufactured of photopolymer resins using polymer jetting (PolyJet) technology. Two critical geometrical features of the specimen were investigated. The variability of the measurement system was determined by Gage repeatability and reproducibility (Gage R&R) methodology. Machine and process capabilities were performed in relation to the defined tolerance limits and the results were analyzed based on the requirements from the statistical process control. The results showed that the EDEN 350 system capability and PolyJet process capability enables obtaining capability indices over 1.67 within the capable tolerance interval of 0.22 mm. Furthermore, PolyJet technology depositing thin layers of resins droplets of 0.016 mm allows for manufacturing in a short time of a high volume of parts for mass production with a tolerance matching the ISO 286 IT9 grade for radial dimension and IT10 grade for linear dimensions on the Z-axis, respectively. Using microscopy analysis some results were explained and validated from the capability study. -
Root Cause Analysis in Health Care Tools and Techniques
Root Cause Analysis in Health Care Tools and Techniques SIXTH EDITION Includes Flash Drive! Senior Editor: Laura Hible Project Manager: Lisa King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production: Johanna Harris Executive Director, Global Publishing: Catherine Chopp Hinckley, MA, PhD Joint Commission/JCR Reviewers for the sixth edition: Dawn Allbee; Anne Marie Benedicto; Kathy Brooks; Lisa Buczkowski; Gerard Castro; Patty Chappell; Adam Fonseca; Brian Patterson; Jessica Gacki-Smith Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a Joint Commission Resources publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. -
Process Optimization Methods
Process optimization methods 1 This project has been funded with support from the European Commission. This presentation reflects the views only of the auth or, and the Commission cannot be held responsible for any use which may be made of the information contained therein. LLP Leonardo da Vinci Transfer of Innovation Programme / Grant agreement number: DE/13/LLP-LdV/TOI/147636 Contents Contents .................................................................................................................................................. 2 Figures ..................................................................................................................................................... 2 Introduction ............................................................................................................................................. 4 Definition of Process optimization .......................................................................................................... 4 Process optimization methods- Approaches ........................................................................................... 5 BPR – Business process reengineering ................................................................................................ 5 Lean Management............................................................................................................................... 5 Kaizen (CIP) ......................................................................................................................................... -
Root Cause Analysis of Defects in Automobile Fuel Pumps: a Case Study
International Journal of Management, IT & Engineering Vol. 7 Issue 4, April 2017, ISSN: 2249-0558 Impact Factor: 7.119 Journal Homepage: http://www.ijmra.us, Email: [email protected] Double-Blind Peer Reviewed Refereed Open Access International Journal - Included in the International Serial Directories Indexed & Listed at: Ulrich's Periodicals Directory ©, U.S.A., Open J-Gage as well as in Cabell‟s Directories of Publishing Opportunities, U.S.A ROOT CAUSE ANALYSIS OF DEFECTS IN AUTOMOBILE FUEL PUMPS: A CASE STUDY Saurav Adhikari* Nilesh Sachdeva* Dr. D.R. Prajapati** ABSTRACT Quality can be directly measured from the degree to which customer requirements are satisfied. Some problems were reported by the customers of the automobile company under study in the fuel pumps; which is used in an automobile to transfer the fuel from fuel tank to fuel injection system after filtration.This paper presents the implementation of Quality Control tools– Check Sheet, Fishbone Diagram(or Ishikawa Diagram), ParetoChartand 5-Why analysis tools for identification and elimination of the root cause/s responsible for malfunctioning of the fuel pump in customers‟ cars. From the Check sheet and Pareto analysis, two major defects were identified which accounted for more than 80% of the problems being reported. The root causes of these two defects affecting the product quality of the company were then further analyzed using the 5- Why analysis. Keywords: Quality Control Tools, Ishikawa Diagram, Pareto Chart, 5-Why Analysis * Undergraduate Student, Department of Mechanical Engineering, PEC University of Technology, (formerly Punjab Engineering College), Chandigarh ** Associate Professor& Corresponding Author, Department of Mechanical Engineering, PEC University of Technology (formerly Punjab Engineering College), Chandigarh 90 International journal of Management, IT and Engineering http://www.ijmra.us, Email: [email protected] ISSN: 2249-0558Impact Factor: 7.119 1.