...Root Cause Analysis Healthcare facilities that are Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited are required to implement root cause analysis as part of their obligation. The root cause analysis team strives to assess and improve patient outcomes as specific situations occur by forming a team of experts that were involved in the situation. Cases are reviewed and processes are implemented to correct the errors that took place. Four key questions are asked, what happened, why did it happen, what can be changed to prevent it from happening again and how are we going to evaluate the change. This process takes place soon after the event so details are not forgotten. The professionals involved in the root cause analysis would take on roles. The team leader would be a representative from risk management. The nursing supervisor that was working on the day of the event would be the recorder. The team members would include the manager of the emergency department, the RN, LPN, and physician involved with the patient from the emergency department. The advisor would be the chief nursing officer or another member of the executive staff. The first thing is to review the many causative factors that were in place on this particular day. There was inadequate staffing for the emergency department for the number and high acuity of patients that were being treated. There was a hospital protocol for conscious sedation that was not followed. The nurse...
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...Root Causes of Environmental Issues Holly Regan SCI/275 July 27, 2014 Stacy Murphy Root Causes of Environmental Issues The failure to address the root causes has led to most of the environmental unsustainability issues we have today. Harich (2012), asks, “Does environmental sustainability fall into the class of problems that are inherently insolvable?” I agree with the views that reflect the majority rule in the sense of not addressing the root causes as they present themselves to be among the major contributors for unsustainability in our environment and the destruction of our planet. Some conclude that a small parcel of land removed of trees is harmless, but, in fact, the failure to manage and restore ecosystems properly over the last several decades has brought us to where we are today. The point, all too often ignored, is this trend is being driven in large part by a combination of population growth and increasing per capita consumption, and it cannot long be continued without risking a collapse of our now-global civilization, (Erhlich, 2008). I do not agree with Frontierism. The blatant ignorance of destruction to the environment and surrounding ecosystems is ridiculous. Frontierism affects environmental sustainability by creating disruption within the ecosystem by removing what has taken thousands of years to produce and interrupts the balance within the surrounding environment for renewable resources. According to our text, “lacking an understanding of...
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...flcfReflection Paper #1 Inez Burrell March 19, 2013 The Experiential Learning Activity served as a significant tool to put the process of conflict mapping into perspective. Conflict mapping is a type of model that simplifies a complex social conflict such as the ones taking place in Voinjama, Liberia. It emphasizes the most important elements and systematically asks questions about issues, parties, strategies, and key components. When developing a conflict map, it is also important to focus on the parties’ grievances, trigger events, and root causes of the conflict. Although conflict mapping is used to facilitate the analysis of the conflict, it can actually make the process harder since there are so many possible answers. Each person analyzing the conflict may have different viewpoints for the components that make up that specific conflict as a whole. There are no right or wrong answers because each idea could be vital in solving the specific problems in that conflict. The reality of this became applicable during the Experiential Learning Activity because each group felt differently about the specific issues going on in Liberia. During the Experiential Learning Activity, the class was split into teams in order to analyze the conflict through the use of conflict mapping. As a group, it was decided that the parties involved in the conflict were the Mandingo and Loma. However, looking at the conflict in a broader sense it was decided...
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...TUI UNIVERSITY Module 2: Case Effective support for information users ITM 301: Principles of Finance Date: 25 January 2011 Effective support for information users In this module I will address the question of “What are the five to seven important strategic things that a company can do to ensure that its Information Technology (IT) users get adequate technical support”. "Our clients know, within minutes, if their customers are unsatisfied with a service call - and they can react accordingly." says Anthony Lacopo, President and CEO for Utopia Image who believes that real-time service is of great value to the merchants. "Great service providers increase loyalty by constantly measuring service quality and adapting their customer assistance service in real time, which is drastically different than counting the number of tickets closed or resolved. Don't confuse customer satisfaction with customer service." The five strategies that I feel are most important to having an effective helpdesk and which will afford user with the most desirable technical support are the areas which I will discuss in more detail below. The first area is to train & empower help desk agents. “Complacency is the biggest challenge we face today,” says Technical Support Manager Drew L. Jaehnig of the Defense Information Systems Agency (www.disa.mil). “Education and an infusion of enthusiasm for change are the best ways to overcome that challenge. Make training a priority and be sure that...
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...company in the U.S. and Levendary Café China’s operation style * The U.S. market emphasizes on the customer experience – provides place to sit and eat * The China market has a fast food establishment – e.g. take out counters and use of cheap furniture or no furniture at all (Quick casual dining) * Chen has a high reluctance to conform with the company’s planning and reporting processes * Lack of communication between the U.S. headquarter and the China market Secondary Issues * Different financial reporting processes in China and the U.S (not U.S. GAAP) * Is Chen really the best candidate for the role he serves or should he be replaced? Root Cause Analysis Symptoms: Most Levendary Café stores in China have different designs and menus compared to the U.S. ones Root causes: Chen has too much freedom to manage the Chinese subsidiaries. Available Alternatives * Develop a more standardized approach across all Levendary restaurants in the Chinese market * Take reference of KFC and other successful American restaurants approach * Adapt to a certain extent to satisfy specific tastes and preferences in the...
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...Problem Identification David is convinced that his boss wants to fire him. He will not meet 6-month and 12-month sales plan unless he uses creative accounting. Root Cause Analysis There is relationship conflict between David and his boss. Some elements did not fit with each other (open system). Carter had his own favorite, so promoting David created political situation (individual–informal organization, work–informal organization). Promotion rules were faulty, as David was promoted without his boss consent and basing on one presentation (work-formal organization). Above mentioned are situational factors in MARS model. Looking at abilities David had little agreeableness expressing his displeasure with flight booking and making impression of being pompous. Although very assertive, hid did not talk to Carter to explain political situation. David also did not have clear role perception as subordinate to Carter. He did not submit requested information or did it in unsatisfactory way, e.g. status of Meryll Lynch. He did not inform the office, where he was, if he changed plans. It made his position weaker to question Carter’s sales plans. After talking to clients, he believed Carter was too optimistic or even had fabricated forecasts to get promoted. Solution Building David should start obeying rules (call the office and inform about his whereabouts, deliver information Carter asks for, hand in assignments...
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...STATEMENT OF THE PROBLEM Course Project Component for Unit 1 of ED7662 – Designing Training and Performance Solutions Table of Contents Organizational Context 4 Performance Gap 4 Significance of the Problem 5 Results of the Root Cause Analysis 6 Key Stakeholders 7 References 8 List of Tables Table 1.1: Performance Gap 5 Table 2.1: Key Stakeholders 7 Client Organization Out of this World IT Solutions Organizational Context Out of This World IT Solutions is an IT Solutions firm whose specialty is the development of technical solutions designed to interconnect internal and external systems enabling secure, seamless integration with customers, partners and suppliers. The company has made a commitment to the state of New Jersey to hire five hundred employees within the next five years. Performance Gap Because the company has a commitment to the state they are gearing up their efforts to bring forth the needed workforce to make particular cities an IT hub. The performance issue is between the Talent Acquisitions and Training Departments. The Talent Acquisitions Department recruits the workforce and conveys to the Training Department who is expected to start and when their orientation date will be. Lately there are many inconsistencies with the process of notifying the Training Department. The performance issues are outlined...
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...drug tests, and policy booklets. Carl found while reviewing the new trainee files that several problems are present. Some of the applications were incomplete, drug screening was not complete, and orientation manuals were incomplete or missing pages. Furthermore, a reservation by technology services for the training room is present throughout the month of June. (University of Phoenix, 2006) Key Problems Three problems are readily apparent; employee applications are incomplete or missing data, three training manuals are currently on hand with 15 needed and the training room is reserved for the month of June. Without further investigation, root-cause analysis is mere speculation. Based on the facts presented in the case study, this author has determined several root-cause factors, which may have contributed to this calamity. These root causes stem from two sources, Carl Robins and ABC, Inc. Carl could have overstated his qualifications prior to hiring upon which a hiring decision was rendered or does he have poor work ethics and incompetent. Further, based on the timeline presented, it appears that Carl is disorganized, found wanting...
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...SEARS CASE STUDY 1.What were the initial indications of the problem? 2.What was the organizations reaction ? 3.What was the result of their reaction? 4.What should the organization have done ? 5.Identify significant symptoms and root causes ? 6. What must they now do to rectify the issues ? Summary : Faced of declining revenues (an average of 8% per year for the past three years), shrinking market share (an average of 3 % per year for the past five years) and an increasingly competitive market (with an average increase of 20% in automotive stores over the past three years). the management of Sears, failed to raise their level of thinking to the Explore, Discover and Design phase of the Model. Instead they implemented a series of policies and procedures which gave pressure to bringing sales lead to the motivate of employees that misleading and selling unnecessary parts and services to the customers. ------------------------------------------------------------------------------------------------------------------------ Answer ISSUE STATEMENT : Facing an average of 8% per year decline on revenues for the past three years, shrinking market share of 3% per year for the past 5 years, as well as the increasing number of competitors, the management of Sear roebuck & co. had failed to think critically and strategically in order to come up with a new, suitable plan but spurring performance of its employees via a flawed incentive compensation scheme which resulted in misleading...
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...OakTable member, Oracle ACE Director Certified DBA -7.0,7.3,8,8i,9i &10g Specializes in RAC, performance tuning, EBS, & Exadata Chief DBA with OraInternals Co-author a few books Email: rshamsud@orainternals.com Blog : orainternals.wordpress.com Web: www.orainternals.com ©OraInternals Riyaj Shamsudeen 2 Golden rules of RAC diagnostics 1. Beware of top event tunnel vision. 2. Eliminate infrastructure as an issue. 3. Identify problem instance(s). 4. Review Send side metrics, and not just Receive side metrics. 5. Use histograms to identify any abnormalities, and not just averages. ©OraInternals Riyaj Shamsudeen Top event tunnel vision n In RAC, the root cause can be hidden in other node and might not show up in the Top-5 wait events. Impact of side effect events can be much, much worse then actual root cause event itself. Performance of the instances are intertwined. Performance of background processes in one node, can affect the application performance in the all other nodes. n n n ©OraInternals Riyaj Shamsudeen Top event tunnel vision ..2 Example 1 ©OraInternals Riyaj Shamsudeen 5 Top event tunnel vision ..3 Example 2 ©OraInternals Riyaj Shamsudeen 6 Top event tunnel vision ..4 Example 3 ©OraInternals Riyaj Shamsudeen 7 Problem node Example 3 (continued) ©OraInternals Riyaj Shamsudeen 8 gc buffer busy A BL request for file #5, block #8 is pending. gc buffer busy acquire FG2 gc current...
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...markets. JITD program faced internal resistance by Barilla's commission based sales force due to lack of knowledge and need of a program like JITD. Issue(s) Identification Internal resistance by Barilla's sales force Poor communication internally and out side the organization with customers and ultimately with end consumers. Cultural within organization and outside Customers are not willing to share the data due to unfamiliarity of the program and in some case its more to cultural issue. Environmental and Root Cause Analysis Complex production system No forecasting or sales data available Canvas based sales system Large no of SKUs (800) Alternatives and/or Options Barilla's top management should pursue sales force to understand the need of JITD and should be on board with this program. Implement a JITD program within Barilla's own CDC to prove the results. Barilla's should drop this idea of JITD program and think of addressing the root causes like change in production system reducing no of SKUs which will cost more than JITD implementation. Recommendation and Implementation Barilla should implement JITDs program by implement this enforcing this stratgey with top management. Plan JITDs implementation by...
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...Aphasia comes from the Greek root word, “aphatos”, meaning “speechless”. It is a language disorder in which there is an impairment of any language modality which may include difficulty in producing or comprehending spoken or written language. Aphasia occurs in men and women alike and although it is more common in middle-aged adults it may also occur in children. Depending on the area and extent of the brain damage, someone suffering from aphasia may be able to speak and not write, or vice versa. Aphasia may also display a wide variety of other language deficiencies in language comprehension and production such as the ability to sing and not speak. Aphasia may also co-occur with speech disorders such as dysarthria or apraxia of speech, which is now a disorder in itself ((Risser, Anthony H.; Spreen, Otfried (2003). Assessment of aphasia. Oxford [Oxfordshire]: Oxford University Press).). Both resulting from brain damage. Dysarthria is a motor speech disorder resulting from a neurological injury and characterized by poor articulation. Apraxia is a disorder caused by damage to specific areas of the cerebrum and is characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the desire and ability to perform the movements (wikopedia). One can understand how both of these disorders correlate closely to the language disorder aphasia, rather taking an in depth look or just an overview. Aphasia is caused by damage to one or more language...
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...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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...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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