A Study on Implementation of Poka– Yoke Technique in Improving the Operational Performance by Reducing the Rejection Rate in the Assembly Line
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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 -
Implementation of Kanban, a Lean Tool, in Switchgear Manufacturing Industry – a Case Study
Proceedings of the International Conference on Industrial Engineering and Operations Management Paris, France, July 26-27, 2018 Implementation of Kanban, a Lean tool, In Switchgear Manufacturing Industry – A Case Study Shashwat Gawande College Of Engineering, Pune Department of Industrial Engineering and management Savitribai Phule Pune University Pune, Maharashtra 44, India [email protected] Prof. J.S Karajgikar College Of Engineering, Pune Department of Industrial Engineering and management Savitribai Phule Pune University Pune, Maharashtra 44, India [email protected] Abstract Kanban is a scheduling system for lean and just in time manufacturing industries or services firms. It is a very effective tool for running a production system as a whole, in this system problem areas are highlighted by measuring lead time and cycle time of the full process the other benefits of the Kanban system is to establish an upper limit to work in process inventory to avoid over capacity. The objective of this case study is to implement a standard Kanban System for a Electrical manufacturing MNC company. With this system, the firm implemented use of just in time to reduce the inventory cost stocked during the process. This case study also shows that the Kanban implementation is not only bounded to the company but to their vendor also, from where, some of the components are been assembled. A replenishment strategy was also developed, tested and improved at the company location. A complete instruction manual is also developed as a reference Keywords Value Steam Mapping, Kanban, Root Cause Analysis, Replenishment Strategy 1. Introduction Lean manufacturing or simply ‘lean’ is a systematic method for waste reduction within a manufacturing system without affecting productivity. -
Sep 0 1 2004
AEROSPACE MERGERS AND ACQUISITIONS FROM A LEAN ENTERPRISE PERSPECTIVE by JUNHONG KIM B.S., Chemical Engineering Seoul National University (1998) SUBMITTED TO THE SYSTEM DESIGN AND MANAGEMENT PROGRAM IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN ENGINEERING AND MANAGEMENT at the MASSACHUSETTS INSTITUTE OF TECHNOLOGY June 2004 @0 2004 Junhong Kim. All rights reserved The author hereby grants to MIT permission to reproduce and to distribute publicly paper and electronic copies of this thesis document in whole or in part. Signature of Author......... ........................ Junhong Kim /ste7&Ies 'and Management Program February 2004 Certified by ... .........I . ...................... Joel Cutcher-Gershenfeld Executive Director, Engineering Systems Learning Center Senior Research Scientist, Sloan School of Management Accepted by ....................................................... -........................... Thomas J. Allen Co-Director, LFM/SDM Howard W. Johnson Professor of Management r A c c ep te d b y ............................. ......... ............................................................................................ David Simchi-Levi Co-Director, LFM/SDM MASSACHUSETTS INSTITUTE| Professor of Engineering Systems O.F TENL GYL.J SEP 0 1 2004 BARKER LIBRARIES Room 14-0551 77 Massachusetts Avenue Cambridge, MA 02139 Ph: 617.253.2800 MITL-ibries Email: [email protected] Document Services http://Iibraries.mit.eduldocs DISCLAIMER OF QUALITY Due to the condition of the original material, there -
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. -
Setting the Stage for Lean Manufacturing Success
Automotive SETTING THE STAGE FOR LEAN MANUFACTURING SUCCESS AUTHOR Despite careful study of lean production, many manufacturers miss out on Ron Harbour lean’s benefits—including lower costs, higher product quality, and greater employee productivity. Why? Beguiled by lean’s business systems and technical tools, they neglect the most important—and least understood— key to executing lean: people systems. Lean manufacturing has been active for a long time, traveling a 30-plus-year journey in the West. While the auto industry has led the effort, lean is now being broadly applied across a multitude of industries, ranging from hospitals and pharmaceuticals to electronics and aerospace. In the automotive production industry alone, a wealth of lean production programs has cropped up, as variations on the renowned Toyota Production System and Ford’s much earlier waste-reduction efforts. (See “Henry Ford’s Philosophy.”) HENRY FORD’S PHILOSOPHY As long as a century ago, Henry Ford embodied lean manufacturing philosophy. He believed that by controlling every link in his industry’s value chain, he could minimize the time it took to transform raw materials into manufactured vehicles. He could thus cut costs and create cars that could be sold at prices accessible to virtually everyone. Ford owned iron ore mines for the production of steel, beaches where sand could be gathered to make glass, even cattle ranches to serve as sources of leather for his autos’ upholstery. In today’s world of fractured value chains, where different entities own different links, few people remember Ford’s approach to taking time and cost out of the auto manufacturing process. -
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. -
The Extent of Implementation of Lean Six Sigma Within Commercial Banks in Kenya
IOSR Journal of Business and Management (IOSR-JBM) e-ISSN: 2278-487X, p-ISSN: 2319-7668. Volume 18, Issue 12. Ver. II (December. 2016), PP 31-37 www.iosrjournals.org The Extent of Implementation of Lean Six Sigma within Commercial Banks in Kenya Beatrice Chelangat Abstract: The objectives of this study were to find out the extent to which Lean Six Sigma is implemented within commercial banks in Kenya. The respondents were made up of managers from these commercial banks in the Kenyan banking industry. The study adopted exploratory research. Primary data was collected using questionnaires and analyzed using descriptive statistics and factor analysis. The study found that the following application of tools and techniques of Lean and Six Sigma were used to a large extent; Voice of the Customers (VOC), Cause and effect analysis, Total Quality Management (TQM), Cross -functional work teams, Continuous Improvement (Kaizen), –Define- Measure- Analyze-Improve and Control (DMAIC) ,Total Preventive Maintenance and Plan, Do, Check, Act (PDCA). The study also found that two main ways through which the banks knew about Lean Six Sigma were through professional publications and through top management. Key Words: Lean Six Sigma I. Introduction Over the past decades, business organizations have embraced a wide variety of management programmes that they hope will enhance competitiveness. Currently, two of the most popular programmes are Six Sigma and Lean management. According to Wang & Chen (2010), Six Sigma approach is primarily a methodology for improving the capability of business processes by using statistical methods to identify and decrease or eliminate process variation. Its goal is reduction of defects and improvements in profits, employee morale and product quality. -
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. -
Quality Control
Topic Gateway Series Quality control Quality Control Topic Gateway Series No. 37 1 Prepared by Bill Haskins and Technical Information Service July 2007 Topic Gateway Series Quality control About Topic Gateways Topic Gateways are intended as a refresher or introduction to topics of interest to CIMA members. They include a basic definition, a brief overview and a fuller explanation of practical application. Finally they signpost some further resources for detailed understanding and research. Topic Gateways are available electronically to CIMA members only in the CPD Centre on the CIMA website, along with a number of electronic resources. About the Technical Information Service CIMA supports its members and students with its Technical Information Service (TIS) for their work and CPD needs. Our information specialists and accounting specialists work closely together to identify or create authoritative resources to help members resolve their work related information needs. Additionally, our accounting specialists can help CIMA members and students with the interpretation of guidance on financial reporting, financial management and performance management, as defined in the CIMA Official Terminology 2005 edition. CIMA members and students should sign into My CIMA to access these services and resources. The Chartered Institute of Management Accountants 26 Chapter Street London SW1P 4NP United Kingdom T. +44 (0)20 8849 2259 F. +44 (0)20 8849 2468 E. [email protected] www.cimaglobal.com 2 Topic Gateway Series Quality control Definition Definitions -
Implementing Lean Service Operations: a Case Study from Turkish Banking Industry
İşletme Fakültesi Dergisi, Cilt 10, Sayı 1, 2009, 171-198 IMPLEMENTING LEAN SERVICE OPERATIONS: A CASE STUDY FROM TURKISH BANKING INDUSTRY Sabri Erdem*, Koray Aksoy** ABSTRACT This paper describes lean management and its application in banking industry. Since lean management eliminates waste effectively in manufacturing environment with significant outputs, service industry has started to focus on lean implementations. In this sense, this paper is a pioneer especially for banking in service sector in Turkey to eliminate waste by means of lean methods. For this reason, a branch of a nationwide state bank in Aegean region was selected as pilot to collect data by observing customers, employee and operations. After analyzing the collected data, some improvements due to eliminations of unnecessary operations were offered. Our results show that significant improvements in banking sector are easy to achieve just by focusing value adding operations. Obtained results are also valid for other branches of the bank. Keywords: Lean Service Management, Lean Thinking, Efficiency in Banking YALIN HİZMET İŞLEMLERİ UYGULAMASI: TÜRK BANKACILIK ENDÜSTRİSİNDEN BİR ÖRNEK OLAY ANALİZİ ÖZET Bu çalışmada yalın yönetim ve bankacılık uygulaması ele alınmaktadır. Yalın yönetimin imalat ortamında anlamlı çıktılar sağlayacak şekilde atıl kaynakları ortadan kaldırmasından dolayı hizmet endüstrisi de yalın uygulamalarına odaklanmaya başlamıştır. Buradan hareketle, bu çalışma, özellikle yalın araçları kullanılarak Türkiye’de bankacılık sektöründeki atıl kullanımın ortadan kaldırılması anlamında öncü çalışmalardan birisi olmaktadır. Bu amaçla devlet bankalarından birisinin Ege Bölgesi’ndeki şubelerinden birisi pilot uygulama alanı olarak seçildi ve bu pilot çalışma alanında müşteriler, banka müşteri temsilcileri ve operasyonlar üzerinde gözlemler yapılarak veri toplanmıştır. Toplanan veriler analiz edildikten sonar gereksiz işlemlerin ortadan kaldırılmasına bağlı olarak bazı iyileştirmeler önerilmektedir. -
Modular Kaizen: Dealing with Disruptions Is a Publication of the Public Health Foundation, with a Limited First Printing in March 2011
Modular kaizen: Dealing with Disruptions is a publication of the Public Health Foundation, with a limited first printing in March 2011. Suggested Citation Bialek, R, Duffy, G, Moran, J. Modular kaizen: Dealing with Disruptions. Washington, DC: the Public Health Foundation; 2011. Additional Resources To find other Quality Improvement publications, please visit the Public Health Foundation bookstore at: http://bookstore.phf.org/ To explore free tools, resources and samples, please visit the Public Health Foundation website at: http://www.phf.org/Pages/default.aspx _______________________________________________________________________ Modular kaizen: Dealing with Disruptions Modular kaizen Table of Contents Acknowledgement ii Preface and Overview iii Chapter 1: The Value of Performance Management 1 Chapter 2: The House of Modular kaizen 13 Chapter 3: Implementing Performance Improvement through Modular kaizen 23 Chapter 4: A System View of the Disrupted Process 31 Chapter 5: Focus on the Disruption – Develop the Response Team 45 Chapter 6: Modular Flow for Rapid Cycle Improvement 55 Chapter 7: Tri-Metric Matrix 69 Chapter 8: Standardizing and Controlling the New System 77 Chapter 9: Change Management 91 Chapter 10: Daily Work Management: Using Quality Improvement Skills in Daily Work 101 Appendices Appendix A: Dr. W. Edwards Deming 111 Appendix B: Additional References 113 Appendix C: Templates and Examples 117 Appendix D: Author Biographies 133 Index 135 i _______________________________________________________________________ Modular kaizen: Dealing with Disruptions Acknowledgements After ten years of practicing and developing the concepts of Modular kaizen, the authors thank the Centers for Disease Control and Prevention (CDC) for making possible the publication of this book, supported by Cooperative Agreement Number 3U38HM000518. The contents of this book are solely the responsibility of the authors and do not necessarily represent the official views of CDC.