Mistakeproofing the Design of Construction Processes Using Inventive Problem Solving (TRIZ)
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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. -
Implementing SPC for Non-Normal Processes with the I-MR Chart: a Case Study
Implementing SPC for non-normal processes with the I-MR chart: A case study Axl Elisson Master of Science Thesis TPRMM 2017 KTH Industrial Engineering and Management Production Engineering and Management SE-100 44 STOCKHOLM Acknowledgements This master thesis was performed at the brake manufacturer Haldex as my master of science degree project in Industrial Engineering and Management at the Royal Institute of Technology (KTH) in Stockholm, Sweden. It was conducted during the spring semester of 2017. I would first like to thank my supervisor at Haldex, Roman Berg, and Annika Carlius for their daily support and guidance which made this project possible. I would also like to thank the quality department, production engineers and operators at Haldex for all insight in different subjects. Finally, I would like to thank my supervisor at KTH, Jerzy Mikler, for his support during my thesis. All of your combined expertise have been very valuable. Stockholm, July 2017 Axl Elisson Abstract The application of statistical process control (SPC) requires normal distributed data that is in statistical control in order to determine valid process capability indices and to set control limits that reflects the process’ true variation. This study examines a case of several non-normal processes and evaluates methods to estimate the process capability and set control limits that is in relation to the processes’ distributions. Box-Cox transformation, Johnson transformation, Clements method and process performance indices were compared to estimate the process capability and the Anderson-Darling goodness-of-fit test was used to identify process distribution. Control limits were compared using Clements method, the sample standard deviation and from machine tool variation. -
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. -
Decoding the DNA of the Toyota Production System
www.hbrreprints.org The Toyota story has been intensively researched and Decoding the DNA of painstakingly documented, yet what really happens inside the Toyota Production the company remains a mystery. Here’s new insight into the unspoken rules that System give Toyota its competitive edge. by Steven Spear and H. Kent Bowen Included with this full-text Harvard Business Review article: 1 Article Summary The Idea in Brief—the core idea The Idea in Practice—putting the idea to work 2 Decoding the DNA of the Toyota Production System 12 Further Reading A list of related materials, with annotations to guide further exploration of the article’s ideas and applications Reprint 99509 Decoding the DNA of the Toyota Production System The Idea in Brief The Idea in Practice Toyota’s renowned production system (TPS) TPS’s four rules: clude that their demand on the next ma- has long demonstrated the competitive ad- chine doesn’t match their expectations. All work is highly specified in its content, vantage of continuous process improve- They revisit the organization of their pro- sequence, timing, and outcome. ment. And companies in a wide range of duction line to determine why the machine Employees follow a well-defined sequence of industries—aerospace, metals processing, was not available, and redesign the flow steps for a particular job. This specificity en- consumer products—have tried to imitate path. ables people to see and address deviations TPS. Yet most fail. immediately—encouraging continual learn- Any improvement to processes, worker/ Why? Managers adopt TPS’s obvious prac- ing and improvement. -
Mcgraw Hill Construction
SmartMarket Report Lean Construction Leveraging Collaboration and Advanced Practices to Increase Project Efficiency Premier Partner: ■ Design and Construction Intelligence SmartMarket Report McGraw Hill Construction Lean Construction: Leveraging Collaboration and Advanced President Practices to Increase Project Keith Fox EfficiencySmartMarket Report About McGraw Hill Vice President, Product Development Executive Editor Kathryn E. Cassino Harvey M. Bernstein, F.ASCE, LEED AP Construction McGraw Hill Construction’s data, Editorial Advisor and Contributor McGraw Hill Construction analytics, and media businesses— Research & Analytics/ Stephen A. Jones Industry Insights & Alliances Dodge, Sweets, Architectural Record, Editorial Director GreenSource, and Engineering Vice President, Industry Michele A. Russo, LEED AP News-Record— create opportunities Insights & Alliances Harvey M. Bernstein, F.ASCE, LEED AP Managing Editor for owners, architects, engineers, Donna Laquidara-Carr, LEED AP contractors, building product Senior Director, Research & Analytics manufacturers, and distributors to Burleigh Morton Senior Director, Head of Marketing strengthen their market position, size Director, Green Content & William Taylor their markets, prioritize prospects, Research Communications and target and build relationships Michele A. Russo, LEED AP Manager, Content Operations Juan Ramos that will win more business. McGraw Hill Construction serves more than Reproduction or dissemination Art Directors one million customers through its of any information contained -
Moving-On — Beyond Lean Thinking
Moving-on — beyond lean thinking Lauri Koskela1 Abstract Lean Thinking is currently often positioned as the underlying theory of lean production among practitioners and academics, although its originators, Womack and Jones, seem not to have presented it as a theory. This paper endeavours to analyze whether Lean Thinking can be viewed as a theory of lean production. For this purpose, a critical assessment of Lean Thinking is carried out. Lean Thinking is argued to lack an adequate conceptualization of production, which has led to imprecise concepts, such as the term “value”. The five principles of Lean Thinking do not systematically cover value generation, and they do not always encapsulate the core topics in their respective areas. The failure to trace the origin of lean concepts and principles reduces the opportunity to justify and explain them. Despite claims for generality, the application area of the five lean principles is limited to the transformation of mass production, with, for instance, one-of-a-kind production and construction being largely out of scope. It is concluded that it is opportune to move on beyond Lean Thinking, towards a generic theory of production, for acquiring a solid foundation for designing, operating and improving production systems. Keywords: Lean thinking, theory, production Introduction “Lean production is ‘lean’ because it uses less of everything compared with mass production: half the human effort in the factory, half the manufacturing space, half the investments in tools, half the engineering hours to develop a new product in half the time.” This characterization of lean production, as presented in the book The machine that changed the world by Womack, Jones and Roos (1990), captured the attention of production practitioners and researchers worldwide. -
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. -
Learning to See Waste Would Dramatically Affect This Ratio
CHAPTER3 WASTE 1.0 Why Studies have shown that about 70% of the activities performed in the construction industry are non-value add or waste. Learning to see waste would dramatically affect this ratio. Waste is anything that does not add value. Waste is all around, and learning to see waste makes that clear. 2.0 When The process to see waste should begin immediately and by any member of the team. Waste is all around, and learning to see waste makes this clear. CHAPTER 3: Waste 23 3.0 How Observations Ohno Circles 1st Run Studies/Videos Value Stream Maps Spaghetti Diagrams Constant Measurement 4.0 What There are seven common wastes. These come from the manufacturing world but can be applied to any process. They specifically come from the Toyota Production System (TPS). The Japanese term is Muda. There are several acronyms to remember what these wastes are but one of the more common one is TIMWOOD. (T)ransportation (I)ventory (M)otion (W)aiting (O)ver Processing (O)ver Production (D)efects. Transportation Unnecessary movement by people, equipment or material from process to process. This can include administrative work as well as physical activities. Inventory Product (raw materials, work-in-process or finished goods) quantities that go beyond supporting the immediate need. Motion Unnecessary movement of people or movement that does not add value. Waiting Time when work-in-process is waiting for the next step in production. 24 Transforming Design and Construction: A Framework for Change Look for and assess opportunities to increase value through waste reduction and elimination. -
SC2020: Toyota Production System & Supply Chain
SC2020: Toyota Production System & Supply Chain by Macharia Brown Bachelor of Science in Comparative Politics United States Military Academy, West Point 2003 Submitted to Zaragoza Logistics Center in Fulfillment of the Requirement for the Degree of Master of Engineering in Logistics and Supply Chain Management at the Zaragoza Logistics Center June 2005 © 2005 Brown, Macharia. All rights reserved The author hereby grant to M.I.T and ZLC permission to reproduce and to distribute publicly paper and electronic copies of this thesis document in whole or in part. Signature of Author Zaragoza Logistics Center May 10th, 2005 Certified by Prashant Yadav, PhD ZLC Thesis Supervisor Approved by Larry Lapide, PhD. Research Director, MIT-CTL Brown, TPS 0 Toyota Production System & Supply Chain by Macharia Brown Bachelor of Science in Comparitive Politics United States Military Academy, West Point 2003 Submitted to Zaragoza Logistics Center in Fulfillment of the Requirement for the Degree of Master of Engineering in Logistics and Supply Chain Management Abstract Over the past 50 years Toyota created and honed a production system that fostered its ascension in the automotive industry. Furthermore, the concepts that fuel Toyota’s production system extend beyond its manufacturing walls to the entire supply chain, creating a value chain where every link is profitable with an unwavering focus on teamwork, communication, efficient use of resources, elimination of waste, and continuous improvement. This report is a part of MIT’s Supply Chain 2020 (SC2020) research project focusing on Toyota’s production system and supply chain. The study begins by examining the automotive industry, evolution of top 5 automotive companies, and Toyota’s positioning against its main competitors. -
Use Process Capability to Ensure Product Quality
Use Process Capability to Ensure Product Quality Lawrence X. Yu, Ph.D. Director (acting) Office of Pharmaceutical Science, CDER, FDA FDA/ PQRI Conference on Evolving Product Quality September 16-17, 2104, Bethesda, MD 1 2 Quality by Testing vs. Quality by Design Quality by Testing – Specification acceptance criteria are based on one or more batch data (process capability) – Testing must be made to release batches Quality by Design – Specification acceptance criteria are based on performance – Testing may not be necessary to release batches L. X. Yu. Pharm. Res. 25:781-791 (2008) 3 ICH Q6A: Test Procedures and Acceptance Criteria… 4 5 Pharmaceutical QbD Objectives Achieve meaningful product quality specifications that are based on assuring clinical performance Increase process capability and reduce product variability and defects by enhancing product and process design, understanding, and control Increase product development and manufacturing efficiencies Enhance root cause analysis and post-approval change management 6 Concept of Process Capability First introduced in Statistical Quality Control Handbook by the Western Electric Company (1956). – “process capability” is defined as “the natural or undisturbed performance after extraneous influences are eliminated. This is determined by plotting data on a control chart.” ISO, AIAG, ASQ, ASTM ….. published their guideline or manual on process capability index calculation 7 Nomenclature Four indices: – Cp: process capability index – Cpk: minimum process capability index – Pp: process