...need almost instant response on root cause analysis. These issues usually come through email or phone calls from the sales engineers. The steps I follow are, once the issue comes through an email or phone, I file a defect in the defect tracking system with the information at hand, and then the issue goes to engineers to reproduce and perform the root cause analysis. After that, the priority is to find the workaround for customer, provide the feedback in email and wait for customer response on the workaround, in some cases, the customer needs issue fix in the product and that request goes through the product management. I would like to streamline this process, because the email communication for the issues is very confusing and time consuming. Project Selection Method to Evaluate the Process Improvement List of problems: 1. Issues coming through emails do not have enough information about the issue itself, such as platform, configuration, customer setup, priority of issue, frequency of issue. 2. The sales engineers do not file any issue in the defect tracking system and email directly to engineers many a times for customer issues. 3. The emails have multiple issues under one subject matter, adding to confusion of the engineers. 4. The engineering team spends a huge amount of time to gather basic information on issue itself and it causes delay in the root cause analysis. 5. The customer service team is not in loop, so it causes discrepancy in the knowledge...
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...Diagnosing Service Problems Introduction to Services The critical and complex nature of today's business applications has made it very important for IT organizations to monitor and manage application service levels at high standards of availability. Problems faced in an enterprise include service failures and performance degradation. Since these services form an important type of business delivery, monitoring these services and quickly correcting problems before they can impact business operations is crucial in any enterprise. Service-level agreements are used to evaluate service availability, performance, and usage. By constantly monitoring the service levels, IT organizations can identify problems and their potential impact, diagnose root causes of service failure, and fix these in compliance with the service-level agreements. Enterprise Manager provides a comprehensive monitoring solution that helps you to effectively manage services from the overview level to the individual component level. When a service fails or performs poorly, Grid Control provides diagnostics tools that help to resolve problems quickly and efficiently, significantly reducing administrative costs spent on problem identification and resolution. Finally, customized reports offer a valuable mechanism to analyze the behavior of the applications over time. Grid Control monitors not only individual components in the IT infrastructure, but also the applications hosted by those components, allowing you to model...
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...training new unit staff and also the float nurses. “Doctors can be most involved in reducing line entries,” he says, “following the standard work orders to ask every day with every patient, what can we do to reduce line entries?” Before QTN: Limited Data, No Analysis As for data collection, a rigorous requirement of QTN, Hord admits, “Before joining, we did not have good ongoing data collection about line days in our inpatient unit, much less elsewhere. Now, we have built a system to track line days of our entire patient population anywhere.” When a central line-associated bloodstream infection (CLABSI) occurred, the unit did not have any particular follow-up, much less the root cause analysis required by QTN. “Now, when a positive culture comes back, the team receives an email notification, and nurses involved in the care of the patient are quickly interviewed,” says Hord. “Two or three days later, the team convenes for the root cause analysis, and we go through a checklist of questions.” He cites a case of a positive culture for a bone marrow transplant patient. These patients need to be bathed to get the chemo off their skin, so the infection could have been from a waterborne pathogen. During the root cause analysis, the question...
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...----------------------- Energy Trace Barrier Analysis (ETBA) – Qualitative analysis technique used to identify hazards by tracing energy flow into, thru, & out of a system. “Energy hazard” is defind as an energy source tht adversely impacts an unprotectd or vulnerable target. Assessment is conductd by following the energy path to determine if adequate controls are in place to assure undesird energy release does not occur.– Energy flow is tracd through the system operation & energy transfer points are identifid– Barriers to ento energy flow are evaluatd to determine adequacy • ETBA process can be applied at any stage of the project lifecycle & can be very useful for:– Systems design –Developing procedures(e.g., lockout--‐tagout). – Planning/judging operational readiness. – During mishap investigation or making “safe--‐to--‐enter” decisions at mishap sites. ETBA Approach • Examine system & identify all energy sources • For each energy source, trace its path through the system • Identify all targets tht could be vulnerable to the energy source • Identify all barriers in the energy flow path • Determine if existing controls are adequate. Energy Source– any material, mechanism, or process tht contains potential energy tht can be releasd •Electrical •Mechanical •Chemical •Radiation• Sonic• Thermal• Nuclear• Pneumatic• Hydraulic• Others Energy barrier --‐ any design or administrative method tht prevents energy from being releasd or prevents a hazardous energy source from reaching a...
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...Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis The purpose of this root cause analysis is to carefully examine the causative factors, errors, and hazards that led to the sentinel event of Mr. B’s death. Mr. B was 67 year old male that presented to the ED with his son and neighbor. Mr. B stated that he tripped and fell over his dog. Upon assessment Mr. B’s vital signs were stable with the exception of rapid respirations, his left leg was shortened, red and swollen, and pain was rated 10 on 1-10 scale. The first step to a root cause analysis is to identify what happened. In this scenario, the patient is admitted to an ED room after proper triage. Initially, 5 mg diazepam was ordered by the ED Doctor, and administered by Nurse J at 4:05 pm. After five minutes, no status change is noted and Dr. T ordered 2 mg hydromorphone IVP. This is administered at 4:15 pm. Dr. T then ordered an additional 2 mg hydromorphone IVP, as well as an additional 5 mg diazepam IVP. At 4:25 pm a successful reduction of left hip takes place. At 4:30 the procedure is concluded. The patient remained sedated, showing no signs of distress or discomfort. Mr. B is not currently on supplemental oxygen. Mr. B is placed on an automatic blood pressure machine programmed to monitor the blood pressure every five minutes as well as a pulse oximeter. At 4:35 pm Mr. B blood pressure is 110/62 and O2 saturation is 92%. He has no supplemental oxygen, and his ECG and respirations...
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...desired position. * To find the Root Cause of the Gap thus, providing solutions to eliminate/solve the problem and reach the desired goal. | Explain the purposes/uses of the Systems model (3 points) * Understands the parts of the system and how they are connected related to each other. * Identifies the problems occurring in the systems , their causes and provides for a solution for them * Then, identifies what to measure (feedback & monitoring) to determine whether the problem has been solved or measure the current performance in regards to the desired performance. | Check (✓ ) the performance improvement approach you are using: ✓ Discrepancy-Based Model ☐ Systems Model Company Project Paper: Discrepancy-Based Model Note: the points are based on correctly identifying the steps and providing explanation for each of those steps. Fill in any missing information. Points | Identification | Explanations | 2 | Appropriate sequence | Discussion of reason(s) for this sequence. Why these steps in this order? As the Problem Solving Process involves: * Understanding the current situation to analyze the problem or scope of improvement * Then, to define the problem due to which there is a GAP between the current & desired goal –challenges faced to overcome it, its impact on the business. * Determining the underlying CAUSE/CAUSES of the problem and making a list to determine the major cause...
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...Simulation MBA Capstone Tasks: Best Practices If you are in the MBA Capstone course, you can see the light at the end of the tunnel. These best practices are designed to help make the stretch of your educational journey as smooth as possible. A mindset of excellence Your MBA Capstone tasks should reflect your highest quality work; your current state of excellence. The standards are high for the capstone tasks. Doing just enough to get by or good enough will result in re-work and re-submissions. The best practice is to strive for excellence. Read for understanding Read the course of study, task instructions, and task rubrics. Seek clarification on any points that might be subject to multiple interpretations. Do not assume; know. The best practice is to be prepared by reading for understanding. Capsim Simulation The designation of MBA indicates the ability to lead and manage both vertically and horizontally across an organization. It is the ability to maximize organizational success by understanding the organization as a system of integrated and interdependent parts. Successful completion of assessments in your MBA courses signals that you know the theories and competencies; the simulation is an opportunity to demonstrate and apply your skills. The best practices are listed below. 1. Read the Team Member Guide; understand your role and the roles of other team members. 2. Complete the Capsim pre-work. 3. Understand the simulation is challenging, time intensive...
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...the metrics that can provide key insights. Currently, the KPIs used in the CPDN warehouse do not account for the root cause of poor performance or a basis for corrective action. Our past performance levels have been very good but recent complaints from customers and pharmaceutical manufacturers have subjected the system to scrutiny and there is a need to conceptualize a more robust performance management system with a view to maximize customer satisfaction and manage the expectations of key stakeholders. Analysis Exhibit 1 depicts calculations done based on last month’s performance. There were 2000 lines backordered that resulted in backordered sales of approximately $910,000. Furthermore, the backorder rate (Exhibit 2) was at 6.67%. This is one of the indicators that are not currently measured and clearly have a major impact on the business. UPS logistics and CPDN lose credibility every time customers order directly from the manufacturers, putting in question the need for an agency such as CPDN. There is also the issue of customer safety in case drugs are not available in life threatening situations at the hospitals. I believe the key areas of concern with a new performance management system are maintaining confidentiality to avoid collusive trade practices, prioritizing and tracking critical KPIs and developing a robust framework for root cause analysis and corrective action. Recommendations Exhibit 2 depicts a list of nine KPIs that have been suggested to manage...
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...Customer Loyalty Customer Loyalty by definition is a feelings or attitudes that incline a customer to return to a company, shop or outlet to purchase again, or else to re-purchase a particular product, service or brand. In general, the customer loyalty starts with a purchase, and ends with repurchase. Customer staying longer with the company tends to decrease maintenance cost, less prone to price fluctuation and good reference to other customers. “It costs five times more to acquire a new customer than to retain an existing one” (Pfeifer, 2005). For company to remain profitable it is essential for the company to retain its current customers; In other words take care of current customer base before go after new ones. In today’s global market place competition, it is more effective business strategy to retain customer rather than continuously trying to acquire new customers (Anderson, 2004). Empirical data study from (Hallowell, 1996), illustrates that there is a direct relationship between customer satisfaction to customer loyalty, and customer loyalty to profitability. An estimate of the effects of increased customer satisfaction on profitability suggests that attainable increases in satisfaction could dramatically improve company profitability. In this age of internet, customers are empowered with different source of information over the various communication mediums (Griffin, 2002). Now, a company must also allow customers to pull the marketing information they want, when...
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...Unit 10 1- LO1 Understand vehicle systems fault diagnosis criteria and techniques Answer: A process of diagnosis implies detecting or finding a fault or problem. In particular, a root cause fault is described as a core problem that has the potential of resulting in other observable symptoms and abnormalities. It is worth pointing out that a root cause fault need not be directly linked to the observable symptoms. It can also relate to indirect observable symptoms. Fundamentally, the root cause detection is primarily associated with the relevant procedures involved in the correction of abnormal conditions. It is essential to understand that a “problem” or “fault” in a piece of equipment does not have to be as a consequence of the equipment’s complete failure or even involve particular hardware. For example, a problem can be described as either an off-spec product or non-optimal activity. A classic illustration of this situation is a process plant, where in which the failures of hardware may be attributed to non-optimal operation. However, problems in the process plant may as well be as a result of poor quality of the feedstock, poor controller tuning, poor selection of the operating targets, and low...
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...Fine Foods need to expand management team to encompass the needs of the growing organization. When are we seeing the problem? Overall, in the business-Kathy is no longer able to run the operations by herself, the organization is in need of technological advances, and financial analysis going forward. How big is the problem? The problem is reflected by looking at the insufficient inventory and purchasing system, need for better financial planning with opening and consolidating the new store with the struggling store. In addition, Kathy is stretched thin with visiting each store with the frequency that she does. What specifically is the problem? Management team needs to be expanded with dependable people who can focus on different aspects of the business allowing Kathy to focus on the company as a whole. What requirements did the company fail to meet? Failure to prepare a good analysis when expanding to DelMar versus Espanita and now looking to consolidate DelMar with the new store because of fledgling sales. Using technological advances to create a value-added purchasing/inventory system. Having better understanding of customer purchasing cycles and trends. PROBLEM STATEMENT ANALYSIS Identifying issues within an organization is important to determining the overall performance goals within an organization. Creating a problem statement for the issues is the most important step in solving these issues. A good problem statement will contain the following information:...
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...Table of Contents Executive Summary Part 1 Executive Summary Issues Identification Part 2 Issues Identification Environmental & Root Cause Analysis Part 3 Environmental & Root Cause Analysis Alternatives and/or Options Part 4 Alternatives Recommendation Part 5 Recommendations Implementation Part 6 Implementation Plan Monitor & Control Part 7 Monitor and Control Part 8 Conclusion Part 1 Executive Summary Navistar was a worldwide leader in the manufacturing medium and heavy trucks for 17 consecutive years in the North America market. Navistar’s premium conventional trucks were produced at the Chatham assembly plant, which had almost 14 years experience in producing Navistar’s premium line since 1983. Navistar had forecasted increased industry demand for heavy and medium trucks in 1998. Especially, the Chatham assembly plant’s customers had strict requirements to the truck’s quality and delivery date. As the assembly supervisor in Chatham, Andy Ramsz encountered the interior trim quality and delivery problem for the truck. Andy had begun to gather data on the interior trim supply problem and he got the crucial reasons for these problems occurred. These reasons absolutely affected the Navistar’s internal supply process, increased the extra cost as well as reduced the efficiency of the supply management. According to the reasons identified for the trim supply problem, my decision is to set up the improved procedure focused on problems identified...
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...part of the process, and has assumed that the individual either “knows” what the problem is or is presented with the problem by some other person (Newall, et al 1958). Teams often are given ill-defined problems and underdeveloped criteria for evaluation. Teams that rush through the definition stage often waste time by returning to the initial stage. A good way to define the problem is to write down a concise statement which summarizes the problem, and then write down where you want to be after the problem has been resolved. In other to successfully define a problem by an individual or a group the following questions needed to be asked. The objective is to get as much information about the problem as possible. 1. What can you see that causes you to think there's a problem? 2. Where is it happening? 3. How is it happening? 4. When is it happening? 5. With whom is it happening? 6. Why is it happening? 7. Write down a five-sentence description of the problem. Also be specific in your description, including what is happening, where, how, with whom and why. It may be helpful at this point to use a variety of research methods. If the problem still seems overwhelming, break it down by repeating steps 1-7 until the team have descriptions of...
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...Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis A. Aspects of Root Cause Analysis 1. Description of Sentinel Event Nightingale Community Hospital is conducting a root cause analysis of a pediatric abduction which occurred during a post-operative discharge process. “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events are called "sentinel" because they signal the need for immediate investigation and response.” (The Joint Commission, n.d.) In this event, a three year old child was admitted to Nightingale Community Hospital for a bilateral myringotomy. The mother of the child stepped out during the surgery in order to run an errand involving her other child. The mother was told the surgery would take about 45 minutes. The mother relayed that she should be back after the surgery to pick up her child. The mother did not respond after the recovery, even though the recovery nurse called out to the waiting area and paged for the mother. The patient was then transferred to the discharge nurse. The child was agitated waiting for her mother to return. Coincidentally, the father was at the desk and the nurse invited him to see his child. The nurse was relieved as the child changed her affect to one of excitement and called him daddy...
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...Introduction: If we speak about this subject before 15 – 20 years back, the subject would be very unique and most of the people will have no understanding about this. But today, Quality tools understanding and importance has grown among people and organizations. There are many tools that are used among the organizations that are classified as follows: 1. Cause Analysis Tools: includes Fishbone, Pareto, and Scattered Diagram. 2. Evaluation and Decision Making Tool: Decision Matrix, Multivoting. 3. Process Analysis Tool: includes Flow chart, Failure Mode Effects Analysis, Mistake-proofing and Spaghetti Diagram. 4. Data Collection and Analysis Tools: box and whisker plot, check sheet, control chart, Design of experiments, Histogram, Scatter Diagram, Stratification, and Survey. 5. Idea Creation Tools: Affinity Diagram, Benchmarking, Brainstorming, Nominal Group Technique. 6. Project Planning and Implementation Tool: Gantt Chart, Plan-Do-Check-Act (PDCA) Cycle or Plan-Do-Study-Act (PDSA) Cycle. 7. Seven New Management and Planning Tools: Affinity Diagram, Relations Diagram, Tree Diagram, Matrix Diagram, Matrix Data Analysis, Arrow Diagram, Process Decision Program Chart. Quality tools & techniques use statistical knowledge to accumulate data and analyze them. It serves diverse range of medical, computing, industrial, telecommunications and defense. These tools drive improvement throughout the organization. Employee has to at all levels has to master the fundamental Quality...
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