Fishbone Diagram Research Articles

Use of the DMAIC Lean Six Sigma quality improvement framework to improve beta-lactam antibiotic adequacy in the critically ill.

Beta-lactam antibiotics are widely used in the intensive care unit due to their favorable effectiveness and safety profiles. Beta-lactams given to patients with sepsis must be delivered as soon as possible after infection recognition (early), treat the suspected organism (appropriate), and be administered at a dose that eradicates the infection (adequate). Early and appropriate antibiotic delivery occurs in >90% of patients, but less than half of patients with sepsis achieve adequate antibiotic exposure. This project aimed to address this quality gap and improve beta-lactam adequacy using the Define, Measure, Analyze, Improve, and Control Lean Six Sigma quality improvement framework. A multidisciplinary steering committee was formed, which completed a stakeholder analysis to define the gap in practice. An Ishikawa cause and effect (Fishbone) diagram was used to identify the root causes and an impact/effort grid facilitated prioritization of interventions. An intervention that included bundled education with the use of therapeutic drug monitoring (TDM; i.e. drug-level testing) was projected to have the highest impact relative to the amount of effort and selected to address beta-lactam inadequacy in the critically ill. The education and TDM intervention were deployed through a Plan, Do, Study, Act cycle. In the 3 months after "go-live," 54 episodes of beta-lactam TDM occurred in 41 unique intensive care unit patients. The primary quality metric of beta-lactam adequacy was achieved in 94% of individuals after the intervention. Ninety-four percent of clinicians gauged the education provided as sufficient. The primary counterbalance of antimicrobial days of therapy, a core antimicrobial stewardship metric, was unchanged over time (favorable result; P = .73). Application of the Define, Measure, Analyze, Improve, and Control Lean Six Sigma quality improvement framework effectively improved beta-lactam adequacy in critically ill patients. The approach taken in this quality improvement project is widely generalizable to other drugs, drug classes, or settings to increase the adequacy of drug exposure.

Quality-by-design driven approach in the formulation of an anti-ulcer and gastro-protective oral suspension

Objective This work aims to present a Quality-by-Design (QbD) step-by-step methodology to formulate anti-ulcer and gastro-protective oral suspensions. Methods Sucralfate was used as a drug model. The Quality Target Product Profile was established early during preformulation. Viscosity, resuspendability, pH, and density were assessed through the screening of several suspension platforms based on different prototype compositions. A compatibility study between the active pharmaceutical ingredient and the excipients was performed by thermal analysis and infrared spectroscopy. An Ishikawa fishbone diagram and Failure Mode and Effect Analysis were employed to identify the Critical Material Attributes (CMAs), Critical Process Parameters (CPPs), and Critical Quality Attributes (CQAs). CMAs’ and CPPs’ impact on identified CQAs was further assessed through a 22 full factorial experimental design at normal conditions after manufacture and one month at super-accelerated stress conditions. Results: The lead prototype exhibited no physicochemical incompatibilities. The risk assessment tools revealed that the concentration of the wetting agent and the total concentration of thickening agents represented critical factors for the quality profile of the preparation in terms of viscosity. The optimized formulation comprising 1.125 w/v% total concentration of Natrosol 250 HX and Avicel RC 591 exhibited an enhanced performance according to the established profile. Conclusions The analytical and physicochemical tests showed the robustness and compliance of the final preparation with the quality profile. The proposed step-by-step methodology based on QbD, Design of Experiments, and Quality Risk Management presented in our research holds practical implications for local industries and formulation scientists involved in the development of oral suspensions.

Demonstration of Cough Etiquette As an Effort to Reduce Pulmonary Tuberculosis Cases in Sindang Jaya Using a Community Diagnosis Approach

ABSTRACT Pulmonary Tuberculosis is currently still a serious health problem and is very easily transmitted. Indonesia is the country with the second-highest number of new pulmonary TB cases in the world. The Tangerang District Health Service at the end of 2022 found the number of pulmonary TB cases was 8,941 cases. There was an increase of 60% in new cases of pulmonary TB in Sindang Jaya District within 3 months in 2023. It was necessary to determine which villages had the main problem of pulmonary TB. This study aims to know the causes and carry out interventions to reduce new cases of pulmonary TB. Activities are carried out with a community diagnosis approach. A situation analysis is carried out to determine the problem. Identify the cause of the problem using the Blum Paradigm. Prioritization of problems using the Delphi non-scoring technique. Fishbone diagram to determine the root cause of the problem. Intervention plan with log frame goals and plan of action. Intervention is carried out through a demonstration of cough etiquette. There has been an increase in the ability to practice cough etiquette to help reduce the number of new cases of pulmonary TB. It was proven that 50% of the counseling participants could understand and practice cough etiquette well. After taking a community diagnosis approach, the cause of the problem was found and intervention was carried out, so it is hoped that new cases of tuberculosis in the Sindang Jaya Health Center working area will decrease. Keywords: Tuberculosis, Community Diagnosis, Blum Paradigm, Fishbone Diagram

Fulfilling last wishes: improving the compassionate discharge process

BackgroundCompassionate discharges (ComD), commonly known as rapid discharges, are urgent one-way discharges for critically ill hospitalised patients with death expected within hours or less than 7 days, to die at...

Food Safety Risk Analysis of Songkem Duck Using Failure Mode and Effect Analysis (FMEA) Method

Food safety is an essential aspect of human health. Food processed without paying attention to food safety regulations can harm consumer health. This research aims to 1) identify activities with food safety risks, 2) determine the sequence of food safety risks that will be followed up, and 3) determine appropriate food safety risk mitigation. This research uses the Failure Mode and Effect Analysis (FMEA) method and fishbone diagrams. A case study was conducted on the Songkem pak Soleh Bangkalan duck supply chain. The research results show that activities that pose a food safety risk include receiving raw materials, storing raw material stocks, using raw materials and BTP, sanitizing production facilities, and storing finished products. The priority order of food safety risks in the Songkem duck supply chain is based on the FMEA method: storage of finished products, sanitation of production facilities, and storage of raw material stocks. Risk mitigation can be done to prevent food safety risks in storing raw material stocks and storing finished products, namely by controlling water activity (aw) and acidity factor (pH); and controlling the room's atmosphere. Meanwhile, to prevent risks due to sanitation hygiene, namely holding training to increase awareness of the importance of sanitation hygiene for restaurant employees monitoring and maintaining sanitation hygiene in the production environment.

Quality control of garment product using DMAIC Six Sigma

Quality control is intended to ensure that the products are in accordance with the predefined standards. PT. XYZ is a garment company that manufactures products with global target market. Hence, product quality assurance becomes an important issue for PT. XYZ. This research focuses on the Just Brand-MCJA216142 jacket product at the sewing work station on line-4 of PT. XYZ. Preliminary observations show that the number of reworked-products was experiencing an increasing trend. This study aims to determine whether the company has carried out quality control properly. Specifically, the research objectives are to identify the type and level of product defects, identify the factors causing product defects, and provide proper improvement suggestions to reduce the occurrence of product defects. This study applied DMAIC (Define–Measure–Analyze–Improve–Control) Six Sigma concept. The results showed that the quality of the Just Brand-MCJA216142 jacket product has exceeded the Indonesian industry average and is classified as the USA industry average. However, quality improvement is still needed since the products are targeted for the export market. Based on Pareto diagram at the Analyze stage, it was found that the most dominant defects occurred in the Just Brand-MCJA216142 jacket production process were broken threads and puckering. The frequency of occurrence for these two types of defect reaches 23% of the total 16 types of defects. The defects were caused by human, machine, material, method, and environmental factors. Recommendations for improvement at the Improve stage are based on root cause analysis of each causative factor that is identified using a fishbone diagram. This research results strengthen the previous related researches regarding the effectivity of DMAIC Six Sigma for analyzing quality control of products.

Analysis of Bolt Former Machine Effectiveness Using Overall Equipment Effectiveness (OEE) and Six Big Lossess

XYZ a manufacturer of nuts and bolts, frequently faced bolt former breakdowns that resulted in huge losses and disrupted the company's operational efficiency and reputation. To solve this problem, PT XYZ needs to implement an effective maintenance strategy and closely monitor machine conditions to reduce the risk of breakdowns and ensure smooth production. This can be analyzed using the OEE method that exists in the company to detect early symptoms of damage, and continuous monitoring of machine conditions. Based on the calculation (OEE) before maintenance scheduling is made on the bolt former machine is currently 69.34%, which is below the standard (JIPM) of 85%. Therefore, the machine still needs to increase productivity through the OEE and Six Big Losses methods and then proceed with analyzing the problem using a fishbone diagram. The results of the analysis found that the biggest factor of time loss was reduced speed losses of 23.15%. The value of setup and adjustment losses was 7.82%, idling and minor stoppages losses were 7.44%, equipment failure losses were 3.12%, defect losses were 0.99%, and scrap losses were 0.11%. After the implementation of OEE, it has an impact on the level of productivity with the calculation results increasing to 77.78%. The availability value reached 89.90%, the performance value was 87.75%, and the quality value was 99.57%.

Strategi Peningkatan Volume Muatan Kapal Roro Trayek Makassar-Jakarta di PT Bumi Lintas Tama Kalla Lines

This study aims to determine the factors that affect the low volume of cargo and get the right action strategy to increase the volume of cargo of RollOn–RollOff (RoRo) Makassar-Jakarta route at PT Bumi Lintas Tama Kalla Lines. The type of data used in this research is quantitative data, namely about the main size of the ship (LOA, LBP, B, H and T), the ship's cargo capacity, the size of the ship's loading space, the number of ship decks, determining the internal and external factors that influence the handling of Roro Ferry shiploads with interviews and questionnaires and Questionnaire Forms. Using the method with the results obtained from the calculation of the load factor and the determination of the fishbone diagram factors to get the root cause of the lack of RoRo ship cargo volume. The sample in this study were 50 respondents consisting of practitioners at the Port and AMI Maritime Polytechnic Lecturers in Makassar. The results of this study indicate that the company adopts a conventional system that focuses on one side, namely incoming cargo or the Jakarta-Makassar route. In addition, the use of SWOT analysis found that the situation experienced by PT Bumi Lintas Tama is in quadrant IV, indicating an unfavorable situation with various internal threats and weaknesses. It is recommended to focus on strengthening internal strengths and overcoming weaknesses. As for its operational efficiency and performance, it should adopt a more holistic approach and consider using methods other than the fishbone method.

Pendampingan Perencanaan Implementasi dan Evaluasi Program Kesehatan Bebas Anemia Remaja Berkarya

Health program planning was carried out to develop a mature and well-organized health plan to achieve predetermined health goals within a certain timeframe. Based on a systems approach, a survey through questionnaires, and determining priority problems through USG (Urgency, Seriousness, and Growth), the result obtained was that 84% of teenage girls at SMPN 41 Surabaya did not adhere to consuming Iron Deficiency Anemia tablets (TTD). Following that, a root cause analysis of the issue was conducted utilizing a fishbone diagram, and the main cause related to this problem was found, which was the absence of a routine schedule for TTD assistance. Hence, several alternative solutions were given priority based on the MEER method (Methodology, Effectiveness, Efficiency, and Relevance).. From this method, it was concluded that the selected solution that could be implemented was the provision of the "Bebas Anemia Remaja Berkarya" program with the highest score of 400. The implementation of this program increased the understanding of teenage girls at SMPN 41 Surabaya from pre-test to post-test by at least 70% of those present, as well as increasing the adherence to taking Iron Deficiency Anemia tablets by at least 70% of the teenage girls at SMPN 41 Surabaya who were present

Improving the KYC Onboarding Process Using Business Process Re-Engineering: A Case Study of a Foreign Bank in Indonesia

The Know-Your-Customer (KYC) onboarding component in the customer acquisition process became an issue in an Indonesian branch of a prominent global bank. In 2023, the branch received a significant complaint from one of its major clients, noting the inefficiency of its KYC onboarding process, thus garnering attention from local senior management. From 2019 to 2023, there was a steady increase in client dissatisfaction rate and the number of new clients dropping their requests during the KYC onboarding stage. This research aims to identify the pain points in Magnolia Bank’s KYC onboarding process and propose solutions using the Business Process Re-engineering (BPR) approach. Fifteen respondents, including 10 bank employees and 5 corporate clients, were interviewed. Thematic analysis of interview results was conducted and it revealed three major pain points of the process: difficulty in document submission, challenges in requirements, and communication issues. The root cause of these pain points were then analyzed using the fishbone diagram, from which three root causes were discovered: inadequate technology infrastructure, lack of transparency in the process, and insufficient guidance that clients receive from the bank. The BPR approach was taken to fix the problems, the project focused on improving the guidance to clients, enhancing technology infrastructure, and developing a system for clients to track their onboarding progress. The proposed business solution for this research is for Magnolia Bank to develop a dedicated KYC onboarding platform, allowing prospective clients to submit the requirements directly, experience a one-window communication system, and track their KYC onboarding status.

The Efficacy of Evidence-Based Practice Training in Enhancing Decision-Making Competency Utilizing Fishbone Diagrams Among Nurse Managers at Hospital B Bandung

The Efficacy of Evidence-Based Practice Training in Enhancing Decision-Making Competency Utilizing Fishbone Diagrams Among Nurse Managers at Hospital B Bandung

Lessons Learned From Data Falsification During an Academic Course Using A Root-Cause Analysis: A Case Report.

Fabricating data or creating fictitious datasets undermines research credibility with severe consequences. To describe a data falsification incident that occurred during an undergraduate nursing research seminar and share the subsequent corrective measures employed at individual and class levels. The students involved in the falsification were asked to identify the incident's factors using an Ishikawa diagram and the 5M-Model approach, presenting their findings to the class. In guided meetings, students offered diverse perspectives on the incident's causes, thoroughly examining the decision-making process behind data falsification, considering motives and emotions. Despite initial tension, the atmosphere improved as students displayed openness and honesty. The current case study uniquely combines educational concepts with an approach to establishing a constructive organizational culture, incorporating tools from risk management and treatment safety. Academia should study adverse events, engage students in learning, and emphasize the integration of ethical codes in academia and nursing.

Analisis Pengurangan Waste Proses Produksi Pada PT SP Manufacturing

PT SP Manufacturing is a manufacturing company that operates in the field of wire harness production. When making wire harnesses at PT SP Manufacturing, waste still occurs. Waste in the production process is one of the biggest problems this company wants to solve. A defective product is a product that does not meet wire harness production standards so it cannot meet customer demand, and requires more space before rework is carried out, which causes inventory waste (Unnecessary Inventory). Reduced productivity and higher production costs are the result of this waste. The aim of this research is to use value stream mapping to identify waste in the production process and apply lean manufacturing techniques to reduce it. The results obtained are based on identification and analysis of existing problems as well as alternatives and improvements based on the formulation and objectives in the research. The largest waste in the wire harness production process of PT.SP Manufacturing is waste with a weight score of 60.89%, unknown inventory waste with a weight score of 39, 12%. The causal factors are workers who lack concentration, apply excess solder paste to the wire terminals, workers who pursue targets without paying attention to quality, resulting in defective products that require rework. The recommendations given to the company according to the fishbone diagram are proposed improvements to the wire harness production process to reduce defects and unnecessary inventory which refers to people, machines, methods and materials.

Kaizen Implementation in the Motorcycle Tire Testing Stage with the PDCA Cycle

The research was conducted at the tire trial stage at a motorcycle tire production company, which aims to reduce defects in the measurement results at the tire sample trial stage. The company policy stipulates that tire trials are carried out on 10 tire samples taken at random from each of the total production of 250 motorcycle tires. From the samples taken, it was found that the types of tire defects were Cut Sample and Crown Sample as well as tire dimension defects that did not match the target with dimensional defect types namely Pattern Bare and Bead Crack with a total of 60% defects. The method used for improvement with Kaizen through the PDCA cycle, shows several improvement steps based on Fishbone Diagram and 5W1H analysis. The result of this research is the reduction of defects to zero defects (0%), which means that the company's quality objectives can be achieved. With the principle of Kaizen through this PDCA cycle, the company gets very satisfying results, in line with its target of zero defects.

Quality Control Analysis Using Statistical Quality Control (SQC) and Fault Tree Analysis (FTA) Methods in Semoga Laris Tofu Factory

Semoga Laris tofu factory is a business engaged in the production of tofu. This factory produces approximately 80 drums of tofu per day. There are problems faced at this factory, namely the increase in defective products, namely the texture of the tofu that is too soft, dirty tofu, and the shape of the tofu that is too thin. This can lead to decreased consumer confidence. Every day there are at least 10-15% defective products. This study was conducted to determine the types of product defects, the causes of product defects, and propose improvements to minimize defective products in tofu processing. The methods used in this research are Statistical Quality Control (SQC) and Fault Tree Analysis (FTA). The quality tools of SQC method are check sheet, histogram, pareto diagram, P control map, and fishbone diagram. Then proceed using the Fault Tree Analysis (FTA) method to determine suggestions and corrective actions. Based on the results of research using the SQC method, it is known that the number of thin size defects is 46.231, there is dirt on the tofu as many as 16.093 seeds, and the texture of soft tofu is 27.357 seeds. The results of the analysis using the fault tree analysis (FTA) method show that the causes of product defects include insufficient rest time (D2), irregular machine maintenance (E2), insufficient rest time (F1), and no temperature checker. Proposed improvements that can be given are by providing measuring instruments, making machine maintenance schedules, making machine control cards, giving breaks, supervising, giving gifts to workers, and providing thermometers.

The Synergy Model of Quality Tools and Methods and Its Influence on Process Performance and Improvement

Implementing quality tools and methods creates a basic foundation for innovations, sustainability, optimization, and competitiveness in the era of Industry 4.0 and Quality 4.0. This paper aimed to investigate the use of quality tools and methods in the 24 divisions of a mother manufacturing company without the influence of external factors such as geographical location (America, Africa, Asia, and Europe). It was important for the mother manufacturing company to implement a uniform process standard for innovation and performance. Research methods focused on using the Kanban card, Ishikawa diagram, affinity diagram, Flowchart, 5S, OPL, layout, and Pareto analysis. It was determined in this research that the synergy (combination) of quality tools and methods in divisions improves the process performance. This hypothesis was confirmed by the results of implementing quality tools in processes within divisions. A top result was the new innovative model of synergy of the quality tools and methods for divisions of the parent company thus filling a gap in the scientific field. This model created the basis for the uniform process standard in all divisions. The results brought improvements in the processes such as material input inspection, spare parts production, production process, and product packaging. This model could be a proactive instrument for process innovation.

Use of Lean Management Methodology to Reduce the Rate of Unfinished Nursing Care in the Emergency Observation Room: A Quality Improvement Project.

The integration of lean management in optimizing nursing workflow necessitates the careful examination of several factors, including nurses' work efficiency, patient experience, and health outcomes. To evaluate the extent of unfinished nursing care and patient satisfaction, we have incorporated the lean management approach into our quality improvement efforts. This proactive measure aims to address potential adverse outcomes, such as subpar inpatient experiences, escalated occurrence of adverse events, and decreased job satisfaction among nursing staff. We utilized the lean management methodology of value stream mapping in a specific facility between February and August 2021, aiming to pinpoint the crucial areas for enhancing nurses' workflow. By employing fishbone diagrams, we thoroughly analyzed the underlying causes, and subsequently employed the Plan-Do-Study-Act model to execute interventions devised based on these identified causes. Interventions included: (1) specifying the time of doctors' conventional rounds; (2) changing unreasonable scheduling; (3) employing 5S management to manage nursing supplies; and (4) eliminating duplicate papers and electronic reports. After implementing these interventions, the rate of unfinished nursing reduced from 73.4% to 39.6%, and that of finished nursing care during the shift increased from 38.6% to 71.4%. Overtime was reduced from 37.2 ± 22.4 minutes to 14.1 ± 3.6 minutes. The total patient satisfaction score for the Patient Satisfaction Questionnaire short-form increased (P < .05). The lean management of quality improvement methodologies provides effective enhancement to the work efficiency of nurses.

Barriers and Facilitators to Breast and Cervical Cancer Screenings for Hispanic Women in a Rural State

Abstract Introduction The Centers for Disease Control and Prevention (CDC) and the Division of Cancer Prevention of Control administer the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), designed to increase early detection of cancers among low-income uninsured and underinsured women. However, rates of cancer diagnosis and survivorship differ among women of different ethnicities. We investigated two questions: 1) what are the potential barriers and facilitators for women to complete recommended breast and cervical cancer screenings, and 2) are the barriers and facilitators different for Hispanic women when compared to non-Hispanic White women? Methods We used a community-based participatory research approach and mixed methods: qualitative interviews with women enrolled in the program and a systematic process improvement approach to identify root causes of completing or not completing screenings. We conducted semi-structured interviews in English (n = 11) and Spanish (n = 9) and analyzed responses using fishbone diagrams. Results We recruited 20 participants in four categories: (a) non-Hispanic White women who completed screenings (n = 9), (b) non-Hispanic White women who did not complete screenings (n = 2), (c) Hispanic women who completed screenings (n = 7), and (d) Hispanic women who did not complete screenings (n = 2). Among all women, facilitators included assistance from program staff with appointments and reminders. Hispanic women reported barriers including language difficulties and confusion about the program. Non-Hispanic White women identified barriers as confusion about the role of insurance. Conclusions We found that there are differences in barriers and facilitators for non-Hispanic White women and Hispanic women due to language, the role of insurance, and the level of trust in the program. Reasons for not completing screenings for Hispanic women were structural and systemic in nature; reasons for non-Hispanic White women were based on personal choices.

Study of mental workload in public administration managers

The present research is carried out in the Municipal Administration with the objective of studying the behavior of the mental workload in the work places. The procedure used consists of three stages: preparation, experiments and results. The indicators selected for the study are: Simple Reaction Time, Complex Reaction Time, Discrimination Threshold, Depth Perception and Yoshitake Test are selected. SPSS software is used or the statistical analysis of the data, EndNote as a bibliographic manager and VOSviewer for its graphical representation. An Ishikawa Diagram is used to determine the causes that provoke mental fatigue during the working day in the individuals studied. As a result, out of the 12 workers studied, 6 presented extreme risk, 5 a worrying level and 1 a moderate level of mental workload. A proposal of measures to prevent and reduce the effect of mental workload is elaborated.

An integrated hybrid approach for assembly tolerance transfer and allocation

PurposeThis study aims to develop an optimal tolerance allocation strategy involves integrating the unique transfer (UT) approach and the difficulty coefficient evaluation (DCE) routine in an interactive hybrid method. This method combines the strengths of both UT and DCE, ensuring simultaneous utilization for enhanced performance. The proposed tolerancing model manifests an integrated computer-aided design (CAD) tool.Design/methodology/approachBy combining UT and DCE based on failure mode, effects and criticality analysis (FMECA) tool and the Ishikawa diagram, the proposed collaborative hybrid tool ensures an efficient and optimal tolerance allocation approach. The integration of these methodologies not only addresses specific transfer challenges through UT but also conducts a thorough evaluation of difficulty coefficients via DCE routine using reliability analysis tools as FMECA tool and the Ishikawa diagram. This comprehensive framework contributes to a robust and informed decision-making process in tolerance allocation, ultimately optimizing the design and manufacturing processes.FindingsThe presented methodology is implemented with the aim of generating allocated tolerances that align with specific difficulty requirements, facilitating the creation of a mechanical assembly characterized by high quality and low cost. To substantiate and validate the conceptual framework and methods, an integrated tool has been developed, featuring a graphical user interface (GUI) designed in MATLAB. This interface serves as a platform to showcase various interactive and integrated tolerance allocation approaches that adhere to both functional and manufacturing prerequisites. The proposed integrated tool, designed with a GUI in MATLAB, offers the capability to execute various examples that effectively demonstrate the benefits of the developed tolerance transfer and allocation methodology.Originality/valueThe originality of the proposed approach is the twining between the UT and DCE simultaneous in an integrated and concurrent tolerance transfer and allocation model. Therefore, the proposed approach is named an integrated CAD/tolerance model based on the manufacturing difficulty tool. The obtained results underscore the tangible advantages stemming from the integration of this innovative tolerance transfer and allocation approach. These benefits include a notable reduction in total cost and a concurrent enhancement in product quality.