Determine Root Causes Research Articles

Managing Stress From a Systemic Perspective: Occupational Stress Models

The World Health Organization (WHO) defines stress as a “state of worry or mental tension caused by a difficult situation.” Burnout results from chronic occupational stress that has not been well managed, and is the result of both systemic and personal factors. Systemic structures and planning to optimize work environments are the focus of occupational stress models. To effectively manage stress and avoid the detrimental effects of neglecting both its acute and chronic consequences (such as decreased productivity, low morale, interpersonal conflicts, absenteeism, and other negative outcomes), it is essential to examine various occupational stress models to determine root causes and identify issues at the work unit level. [ Psychiatr Ann . 2024;54(10):e287–e291.]

Utilizing Lean Six Sigma and Waste Assessment Model to Reduce Waste in the Hot Rolled Coil Production

The global steel industry is pivotal, driven by substantial demand. In Indonesia, a leading steel manufacturing company, boasting significant production capacities for Hot Rolled Coil (HRC) and Cold Rolled Coil (CRC) products, with capacities of 2,400,000 and 850,000 tons per year. However, current production lags at 1,500,000 and 500,000 tons annually for HRC and CRC. Notably, the production process recorded defect ratios of 15.85%, 15.65%, and 15.56% from 2020 to 2022, with waste waiting accounting for a breakdown time and operating time ratio of ±40%. The study employs Lean Six Sigma to analyze and mitigate waste during HRC production, aiming to augment product value, production efficiency, and cost reduction. Through Value Stream Mapping and Process Activity Mapping, 44.93% of Necessary Not Value- Added Activities (NNVA). In the next stage, critical wastes including waste defects, overproduction, and waiting are selected using the Waste Assessment Model. The Analysis stage employs fishbone diagrams and Failure Mode and Effect Analysis to determine root causes and assess risk. Proposed improvements include toolbox meetings, maintenance scheduling, check sheets, a work roll replacement algorithm, and sensor adjustments, projected to raise sigma values significantly for waste defects, overproduction, and waiting.

Abstract 12852: Process Mapping the Aortic Stenosis Patient Journey

Introduction: In November 2019 the American Heart Association (AHA) launched Target: Aortic Stenosis, an initiative to improve outcomes of aortic stenosis (AS) patients. Utilizing a learning collaborative model with 15 hospitals, the AHA sought to impact the patient journey from diagnosis by echo through definitive treatment. At three years, process mapping was undertaken to outline learnings from the sites. Goals: The goals were to determine the steps that an AS patient follows from diagnosis to definitive treatment, identify gaps in process that prevent diagnosed patients from progressing to appropriate treatment, analyze areas that impact timeliness of this process, and identify changes that can improve identification and movement to definitive treatment. Methods: Site interviews were conducted utilizing the “Five Whys” approach of determining root cause. Sites analyzed three segments of the patient journey: identification, echo report findings, and multidisciplinary valve team (MDT) meeting occurrence. An ideal process map was created identifying areas that impact the patient journey. A prioritization matrix was created outlining the impact and effort of needed changes. Results: Reporting capability in both echo registries and medical records are key to identifying patients but are not commonly available. Previously unreferred patients were identified. Lack of surveillance tools impacts the ability of hospitals to monitor AS patient care. Lack of defined next steps detailed within echo reports prevents patients from receiving appropriate, timely treatment. The MDT meeting is not often recorded in patient records. Surgical patients often do not go through the MDT process. It is difficult for hospitals to impact patients that are initially identified but that do not continue in the system for unknown reasons. Conclusions: There are elements of the patient journey that impact the identification and treatment of moderate and severe AS patients. The prioritization matrix demonstrated solutions to improve processes that range from low effort - low impact to high effort - high impact. Hospitals participating in Target: Aortic Stenosis have identified changes to improve identification of AS patients and impact the timeliness of treatment.

P042 Lean Six Sigma Approach to Improve Non-Invasive Ventilation Patient Care

Abstract Introduction A lean six-sigma (LSS) approach to clinical redesign looks at aspects of patient flow, value to consumer and process inefficiencies. We used LSS quality management approach for clinical redesign of our non-invasive ventilation patient care. Current recommendations suggest that patients using non-invasive ventilation (NIV) require therapy for a minimum of 4 hours per night for optimal health benefits, with less than this amount defined as low adherence. This information is collated for each patient at each clinic visit. The aims of this study were to improve the identification of patients on non-invasive ventilation that are poorly adherent to paediatric specialist support, decrease the time taken for entry of NIV adherence data for all patients and evaluate process/es for scalability for future growth. Methods A LSS approach was used with identification of variation, waste and patient flow concerns in diagnostic stage. Rapid improvement events, diagnostic and solution design workshops were conducted to determine root cause, key issues and possible solutions. A preferred solution was adopted through team collaboration. Results A diagnostic stage identified two key areas: a 45% increase in telehealth and 162 man-hours of manual data entry for patient care. The solution initiated was to extract NIV machine data remotely and automate data collection. Discussion Healthcare is well suited to using the lean six-sigma approach to facilitate team collaboration in all aspects of clinical redesign of a healthcare pathway. Automating aspects of patient care may improve patient health and staff satisfaction.

Outpatient Oncology Fall Risk: A Quality Improvement Project.

Patients receiving cancer treatment are at high risk for falls. No current guidelines or standards of care exist for assessment and prevention of outpatient oncology falls. This quality improvement project's purpose was to 1) describe and evaluate outpatient oncology falls data to determine root cause(s), and develop, implement, and evaluate intervention strategies for future policy refinement, and 2) compare fall rates pre/post implementation of a system-wide Ambulatory Fall Risk Bundle. Retrospective data were used to describe and categorize fall incidence for the University of Kansas Cancer Center over 12 months. Further analyses were conducted to describe fall rates per 10,000 kept appointments pre/post implementation of an Ambulatory Fall Risk Bundle protocol. Semi-structured interviews were conducted with medical assistants and nurse managers to evaluate the initiative's impact, staff satisfaction, and recommendations for refinement. The initial 12-month assessment yielded 58 patient falls retained for further analyses. Most patients were receiving chemotherapy (46, 79%). Common contributing symptoms included dizziness/ faintness and weakness (25, 43%). Tripping/falling over a hazard (12, 24%) and falls during transfer (10, 5.8%) also were cited. Subsequent analyses of fall rates indicated no change. Recommendations resulting from the qualitative interviews included: orthostatic vital sign protocol implementation, redesign of the electronic medical record fall risk alert, stakeholder involvement in protocol development, staff training, and related patient education strategies, and the procurement of additional assistive devices/equipment. System-related policy and culture change, investment in physical and human resource enhancements, and evidence-based protocols are needed to improve outpatient oncology fall rates.

Shifting the Paradigm from Lessons Learned to Lessons Applied through Digitally Enabled Transformation

AbstractLessons learned are generally documented with limited review until the next policy driven decision point. Additionally, data collected in lessons learned repositories may lack the depth necessary to determine root causes, leading to additional disparate data being required. This passive, disconnected approach is an example of the type of current processes that are desired to be supplanted by the outcome of the digital transformation. Our customer defined a task to deliver a pilot incorporating active lessons management, for which we designed around digital engineering principles to facilitate data manipulation and sharing. To deliver the capability, we re‐envisioned the passive lessons learned as active lesson applied by developing an enterprise‐level methodology for identifying root causes and risk mitigations based on lessons learned. We are also evolving a digital ecosystem for implementing the lessons applied methodology. This article serves to provide documentation of our lessons applied methodology and insight to our supporting digital infrastructure and the unique benefits gained from the infrastructure.

Racial Disparities in Sterilization Procedure Performed at Time of Cesarean Section.

While bilateral tubal ligation has historically been performed for sterilization at cesarean delivery (CD), recent data supports the use and safety of opportunistic bilateral salpingectomy during CD to decrease lifetime ovarian cancer risk. Prior studies have described racial disparities in sterilization rates, but there is a paucity of data regarding racial disparities in type of sterilization procedure. Our objective was to determine differences in sterilization procedure type performed at CD by race (Black vs. non-Black) to evaluate for equity in bilateral salpingectomy utilization. We performed a retrospective cohort study of patients included in the American College of Surgeons National Surgical Quality Improvement Program database who underwent sterilization at time of CD from January 2019, to December 2020, identified using Current Procedural Terminology codes. Patients without documented race were excluded. Multivariable logistic regression was used to determine odds of undergoing bilateral salpingectomy compared with bilateral tubal ligation by race while controlling for confounders. Of 28,147 patients who underwent CD, 3,087 underwent concurrent sterilization procedure, and 2,161 met inclusion criteria (Black: n = 279; non-Black: n = 1,882). Black patients were significantly more likely to have hypertension (10.8 vs. 5.3%, p < 0.01), bleeding disorders (3.9 vs. 1.3%, p < 0.01), preoperative anemia (hemoglobin < 11 g/dL; 36.9 vs. 21.3%, p < 0.01), and be of American Society of Anesthesiologist class 3 or higher (29.4 vs. 22.5%, p = 0.01) than non-Black patients. After adjusting for differences, Black patients were almost 50% less likely than non-Black patients to undergo bilateral salpingectomy compared with bilateral tubal ligation for sterilization at CD (adjusted odds ratio = 0.52, 95% confidence interval: 0.36-0.75). Despite evidence that bilateral salpingectomy decreases ovarian cancer risk and is safe at CD, there is a racial disparity in bilateral salpingectomy utilization. While the cause of this disparity is unclear, further research is warranted to determine root causes and equitable solutions. · Opportunistic salpingectomy is recommended for primary prevention of ovarian cancer in patients undergoing pelvic surgery who have completed childbearing.. · Black patients were almost 50% less likely to undergo bilateral salpingectomy compared with bilateral tubal ligation than non-Black patients even after controlling for possible confounders.. · Further research is needed to determine root cause of the racial disparity in bilateral salpingectomy utilization rate..

Characterizing Materials and Electrochemical Changes in a Range of 18650 Li-Ion Cells Cycled to 80% Initial Capacity

Understanding systematic trends in degradation of Li-ion batteries through a broad range of operating conditions is critical to improving their performance. Over the course of the last few years, researchers at Sandia National Labs have been conducting a systematic study of battery cycling behavior. In this study, dozens of commercial NCA (LiNixCoyAl1-x-yO2) and NMC (LiNixMnyCo1-x-yO2) cells were cycled to 80% capacity across a range of temperatures, discharge rates, and depth of discharge windows. Analysis of both in situ electrochemical data and postmortem materials degradation was done and correlated to determine root causes of rapid capacity fade.During cycling, Electrochemical Impedance Spectroscopy (EIS) and Incremental Capacity Analysis (ICA) experiments were conducted periodically. The data from these experiments were used to understand the state of health (SoH) of cycling cells, including SEI formation and Li plating, as well as general mass transport and kinetic properties.X-ray Computed Tomography (XCT) scans completed before cell disassembly showed large scale deformation in the cells’ jelly rolls. For the postmortem analysis, cells in pristine condition and 80% capacity were disassembled, and their electrodes were analyzed with X-ray Diffraction (XRD), Scanning Electron Microscopy (SEM), and Differential Scanning Calorimetry (DSC). These techniques analyzed different aspects of the electrodes’ physical and chemical properties, including Li plating, micro-cracking, SEI layer formation, and phase changes in cathode materials. DSC measurements also provided insight into changes in the degree to which aged electrodes undergo thermal runaway events.Correlation of the postmortem materials analysis with the in situ electrochemical analysis showed that cells with the most rapid rate of capacity fade had multiple degradation mechanisms active during cycling. The scale of this electrochemical and materials evaluation fills in gaps in the literature about commercial Li-ion battery performance.Sandia National Laboratories is a multi-mission laboratory managed and operated by National Technology & Engineering Solutions of Sandia, LLC, a wholly owned subsidiary of Honeywell International Inc., for the U.S. Department of Energy’s National Nuclear Security Administration under contract DE-NA0003525.

Build upon basics: An intervention utilizing safety huddles to achieve near-zero incidence of catheter associated urinary tract infection at a department of Veterans Affairs long-term care facility

BackgroundWhen traditional interventions are used in long term care for catheter associated urinary tract infection (CAUTI) prevention, residual rates are still high despite a decrease. We conducted a quality improvement study focusing our interventions on patient and staff behavioral patterns identified through a structured huddle process to improve upon the basics for CAUTI prevention. MethodsBaseline was from January 2016 to March 2017; the intervention period was from April 2017 to June 2020. We implemented a systematic huddle to determine root cause of each CAUTI and applied lessons throughout the facility. We measured the monthly CAUTI incidence per 1000 urinary catheter days and analyzed the reduction in CAUTI during the intervention period. ResultsCAUTI decreased by 73% during the intervention period compared to the baseline period, with an IRR of 0.27 (95% confidence interval [CI]: 0.11-0.66; P = .004). The number of catheter days per month increased by 4% in the intervention period (17,407 in 39 months) compared to the baseline period (6,440 in 15 months) with IRR of 1.04 (95% confidence interval [CI]: 1.01-1.07; P = .008). No patterns were noted in organisms responsible for CAUTI. ConclusionsOur findings stress the importance of looking beyond the traditional interventions for CAUTI prevention in long term care population. By doing this, interventions can be customized for this special population to achieve optimal outcomes.

‘‘Endless’’ Workload Analysis of Large-Scale Supercomputers

Modern supercomputers are so large and complex that some of their hardware components inevitably go out of order from time to time. Therefore, supercomputer systems require constant and careful health monitoring, and such control is set up in everyday practice of any large HPC center. But a lot of attention should be also paid to the quality of supercomputer usage, describing how fully and efficiently computational resources are utilized. And this task is still far from being solved, leading to system administrators of most supercomputers knowing very little about the quality of their supercomputer job flow as well as possible ways to improve it. In this paper, we present a looped report system that allows to obtain and analyze information of any level of detail about all important aspects describing the quality of the supercomputer workload, starting from the overall system functioning and up to individual job launches. It provides great flexibility by offering an ‘‘endless’’ number of workload analysis scenarios, which allows to determine root causes of various cases of performance degradation using the same approach. This report system is built upon the previously developed TASC software package, aimed at identifying and analyzing performance issues both at the level of individual parallel applications and the entire supercomputer as a whole.

Root cause analysis of pitting corrosion of AA2024 and AA7075 after exposure in salt fog environment

Two grades of anodised aerospace aluminium alloys, AA2024 and AA7075, were analysed to determine root causes of pitting corrosion after the samples were exposed to a salt spray test according to ASTM B177. Methods to investigate pitting corrosion behaviour of the aluminium alloys were divided into two steps: 1) characterisation of pre-exposed (intact) anodised film and stimulated pitting corrosion by polarisation; 2) comparison of samples that passed and failed the salt spray test. The surface properties were characterised by roughness measurements, scanning electron microscope (SEM) and energy dispersion X-ray spectroscopy (EDS). Pitting corrosion was stimulated by potentiodynamic polarisation prior to characterisation of pitting by SEM and EDS to determine pitting initiation point. The results reveal that thickness of the film does not prevent localised corrosion. Cu-bearing intermetallic particles are detrimental to anodic film formation and cause pitting in the film. Potentiodynamic polarisation tests alone cannot determine whether the film will pass or fail the salt spray test for 96 hours.

N-nitrosamine Impurities in Medicines: Toxicity, Formation Pathways, Methods of Determination, and Limits (Review)

Introduction. N-nitrosamine compounds are potent genotoxic agents in animal species and some are classified as probable human carcinogens. This group of genotoxic impurities was found in drugs such as angiotensin II receptor blockers, histamine H1 receptor antagonists, and synthetic antidiabetic drugs. This discovery caused a flurry of alarm in the global pharmaceutical industry and resulted in a series of international investigations trying to determine root causes of nitrosamine formation in medicinal products and to find ways to minimize risks associated with nitrosamine contamination.Text. This paper provides an overview of the current state of the problem. It summarises the main pathways of N-nitrosamine formation in medicinal products at the stages from synthesis of active pharmaceutical ingredients to storage of finished pharmaceutical products. The paper describes the main mechanism responsible for the toxic effect of this group of impurities in human body. It also describes methods of extraction and analysis of N-nitrosamines found in medicinal products. It was demonstrated that high-performance liquid chromatography and gas chromatography-mass spectrometry are a golden standard for the detection of these contaminants. The paper also touches upon the main principles of setting limits for nitrosamine impurities in medicinal products.Conclusion. The data presented give a picture of the root causes of N-nitrosamine formation in medicinal products, as well as current detection and control methods used worldwide. Meanwhile, the paper raises a key issue about the need to develop Russian standards that would control the purity of medicinal products in terms of N-nitrosamine impurities. For that end, it will be necessary to draw on the experience of the leading USA and EU regulatory authorities.

Chlorhexidine Gluconate Application as A Strategy to Reduce Cardiac Implantable Electronic Device Surgical Site Infection

Background: The electrophysiology laboratory within the cardiac procedures unit (CPU) at Michigan Medicine specializes in implanting, exchanging, and extracting cardiac implantable electronic devices (CIED). During routine surveillance of surgical site infections (SSI), an increase in CIED infections (specifically endocarditis) was noted starting in 2016. The predominant organisms involved with infection were skin organisms such as Staphylococcus aureus and coagulase-negative Staphylococcus. Methods: Cases of SSI following CIED implantation were identified using positive microbiology results collected within 90 days of a procedure. Cases were classified using the NHSN SSI definitions. Upon identifying an increase in infections, a work group of key stakeholders was formed to determine root causes. Factors discussed included standardized surgical skin preparation techniques, patient education regarding bathing before and after procedures, types of surgical drapes in use, traffic in and out of procedure rooms during cases, environmental cleanliness of the procedure area, and adherence to the institutional surgical attire policy. In addition to the workgroup, several cases were observed by the IP team. Results: The investigation revealed several areas for improvement. As a first step, a practice of using 2% chlorhexidine gluconate (CHG)–impregnated bathing clothes on patients prior to surgery was implemented for the chest, neck, axilla, and arm. No other changes were implemented during this time period. In the year following implementation, there were zero cases of endocarditis and only 2 superficial SSIs (Figs. 1 and 2). Conclusions: Employing application of CHG to reduce the microbial burden on the skin significantly aided in preventing infections related to CIEDs.Funding: NoneDisclosures: None

Checklists in community care: reducing differences in care delivery between regular and relief staff to improve consistency and client experience

BackgroundToday, healthcare is more complex than just ensuring clients receive quality care; it also involves consistently delivering excellent client experience. A non-profit community support services agency conducted an extensive diagnostic...

P.138 Effects of cannabis use on neural progenitors and neuronal differentiation in humans

An effective and efficient quality management system (QMS) requires a well-equipped toolbox for monitoring processes, determining root cause, and driving continuous improvement. A common approach and lexicon enhance improvement activities as well as communications. Corrective and preventive action, failure investigation, statistical process control, and root cause analysis are critical to success. A well-defined, preplanned inspection management process should also be in the toolbox to present the QMS in the most correct and favorable manner. An ongoing focus on improvement is essential to thrive or even survive in the highly regulated medical device industry. Maintaining acceptable performance levels, meeting quality objectives, and driving continuous improvement require a well-equipped toolbox. There are many approaches, tools, and techniques for improvement. These tools vary in favorability over time. However, they have many similarities. And they are known by an alphabet soup of acronyms such as CAPA, RCA, A3, 5S, 5 whys, Six Sigma, 6Ms, DMAIC, DMADV, DFSS, PDCA, PDSA, TQM, SPC, FMEA, FMECA, FTA, DOE, ANOVA, Cpk, Ppk, C&E Matrix. Medical device manufacturers can benefit by having a rigorous and consistent methodology for problem analysis and improvement. Effective use of these tools can support a culture of data-based decision making. CAPA is the single most important process for improvement and has very specific regulatory requirements.

Determining Root Cause of Construction Waste Generation: A Global Context

Construction sector is one of the main sectors in contributing Gross Domestic Product (GDP) growth rate in every developing country. The rapid growth of this sector directly produces a huge amount of construction waste. Hence, to find out the main root causes of the generation, this paper aimed to determine root causes of the construction waste generation in the construction sector. The research is carried out through triangulation technique (questionnaire survey and practitioner’s validation). This technique is adopted to facilitate cross validation by analysing 38 articles and then the final results have been validated by construction practitioners. A total of 80 root causes were identified from 38 articles and the 5 main root causes determined have scored more than 50% out of the total number of articles. Finally, the result was validated and found out that 87.5% of construction practitioners agree with the findings. The agreed root causes are ‘Constant design changes’, ‘Incorrect storage of materials’, ‘Poor handling of materials’, ‘Effect of weather’ and ‘Mistakes while ordering from suppliers’. Therefore, these initial findings will be able to aid the construction practitioner (contractors, consultants and developers) to be aware of the root causes that is mostly causing construction waste generation.

A Methodological Review of 3D Reconstruction Techniques in Tomographic Imaging.

Computer Vision has provided immense support to medical diagnostics over the past two decades. Analogous to Non Destructive Testing of mechanical parts, advances in medical imaging has enabled surgeons to determine root cause of an illness by consulting medical images particularly 3-D imaging. 3-D modeling in medical imaging has been pursued using surface rendering, volume rendering and regularization based methods. Tomographic reconstruction in 3D is different from camera based scene reconstruction which has been achieved using various techniques including minimal surfaces, level sets, snakes, graph cuts, silhouettes, multi-scale approach, patchwork etc. In tomography limitations of image aquisition method i-e CT Scan, X Rays and MRI as well as non availability of camera parameters for calibration restrict the quality of final reconstruction. In this work, a comprehensive study of related approaches has been carried out with a view to provide a summary of state of the art 3D modeling algorithms developed over the past four decades and also to provide a foundation study for our future work which will include precise 3D reconstruction of human spine.

Shear Fracture and Industrial Overload Failure of Mechanical Fuse Shear Pin

The science and engineering application of fracture is attractive and complex in nature. The notch provided shear pin geometry design for lower and known stress concentration factor engineered for premature shear pin fracture failure. The shear pin is one among type of mechanical fuse, safeguard bigger industrial rotary components by premature failure. The notch provided in shear pin act as reduced notch toughness where crack initiation and propagation starts from notch surface due to overload stress in the system. Advancement in technologically of mechanical fuses is one such key area, with which design of engineered microstructure analysis of shear failure discussed extensively. In the present investigation, shear pin failure were characterized to determine root cause analysis. Visual examination of fracture surface reveals pure ductile adiabatic shear fracture and metallographic examinations reveals non uniform size of spheroidal cementite carbide particles distributed uniformly slipping in coarse ferrite matrix plane of maximum shear stress causes the reason for shear fracture phenomena during crack propagation.

Forensic Engineering Metallurgical Analysis of PTO Air Compressor Rupture and Fire

The coalescer of an air compressor mounted on a utility truck ruptured, resulting in the expulsion of burning oil onto a nearby employee. An investigation ensued to determine the root cause of the injuries. Many potentialcontributing factors were examined, including system and component manufacture, design, installation, maintenance, and use. Metallurgical and failure analysis procedures were used to determine root cause of the system failure and related injuries. A power take-off (PTO)-driven compressor operates at high temperature (200°F) and pressure (110 psig), creating opportunities for dangerous conditions. The system has a safety shutdown control to prevent the system from going over temperature and pressure limits. The exploded coalescer and fire in this case indicated the temperature and/or pressure systems were compromised as well as the control system. Compressor failures are not uncommon; however, violent failures that cause fire and injury are much less common. PTO compressors are relatively simple machines with only about 25 components. However, the proper function of most components is essential to the safe operation of the unit. In this investigation, it was necessary to look at each component relative to its fitness for service and potential contribution to the system failure.

Root cause analysis of rough conical seat grinding problem in fuel pump cylinder head by Shainin methodology

Problem solving plays a major role in quality engineering and it is popularly adopted by manufacturing industry. This study is aimed to determine root cause for rejection of cylinder head due to rough conical grinding problem by Shainin method. This has two major parts, first is diagnostic part which involves finding out the root cause and second is a remedial action part which consist of actual application of findings to rule out the problem. Wear in tool holder assembly is identified as root cause for rough grinding problem. Converging to root cause and validating the same achieved by successful implementation of Shainin tools.