Fishbone Diagram Research Articles

Analysis of spoilage change over improvements on decorator machines with quality control groups (Pareto and fishbone diagrams)

Every company, including PT, has goals they'd like to accomplish. One of the businesses in the two-piece can sector is CPC. Up until now, PT's goal has been to switch products. The CPC is still not fulfilled; specifically, from January 2022 to May 2023, the product replacement time is still 42 minutes, resulting in the waste of 1043 cans, although the objective was set at 30 minutes for the replacement of the product and 800 cans for spoiling (wasted cans). The current issue is that 800 cans are wasted, and the goal product replacement time is 30 minutes. A quality control group was employed in this study's methodology (Pareto and fishbone diagrams). The primary goal of this study is to identify the underlying cause of the 42-minute product replacement time and the wasted 1043 cans. The analysis's findings demonstrated that the issue of resetting the plate is the one that frequently arises while switching out products. Several underlying causes of the reset plate issue were discovered after additional investigation, one of which was the unclear marking on the plate, which led to imprecise results when the plate was installed on the cylinder. Damages the can printing and necessitates a second plate installation, which wastes time and leads to spoilage. Consequently, a repair plan was created and put into action by changing the plate's markings to make installation easier to understand. This led to a quicker process of replacing the product (41 minutes before repair, 32 minutes after repair), as well as a decrease in the number of wasted cans (850 cans before repair, 828 cans after repair).

Causes of quality defects in cassava-based food production: an ishikawa diagram analysis

Causes of quality defects in cassava-based food production: an ishikawa diagram analysis

Determining the Root Causes of Project Delay: A Case Study

The study aims to identify and analyze the reason for the project delay in ABC Company located in the heart of Malaysia specializing in oil and gas and oil and gas-related products. The study utilized observation techniques and data from an official report. The observation was done on an ongoing project and the assessment of record was done on previously completed projects. The outcome of such observation was analysed and simplified using a tool namely the Cause and Effect Diagram or Fishbone Diagram. The study found that shortage of manpower, local authority approval, improper planning, and the COVID-19 pandemic as the root causes that led to project delay.

Development and application of a risk analysis methodology for road traffic accidents

Collision, rollover, swerving, and vehicle fire are road traffic accidents (RTAs) caused by driver, vehicle, and environment-related factors, resulting in diverse severity levels, such as property damages, injuries, and fatality. In addition, vagueness in detectability, e.g., close circuit television and driver admittance, culminates RTAs' risk analysis into a multifaceted problem. The present study performed root cause analysis to investigate RTAs, where the fishbone diagram categorized RTAs (e.g., collision and swerving) and identified primary (e.g., driver and environment) and secondary (e.g., overspeeding and tire burst) root causes. For 1158 km of intercity highways in Qassim (Saudi Arabia), fuzzy-failure mode and effect analysis evaluated 171 failure modes using 3500 RTAs' recorded over three years and knowledge of practice and experts. The study highlights collision, driver-related issues, and property damage as the leading category, root cause, and consequence. Comparing the baseline with the first realistic mitigation (speed camera installation) acknowledged a 53 % reduction in risk probability number. Automated driver assistance systems, rumble strips, variable speed limits, and increasing penalties for traffic violations hypothetically dropped 76 % of cumulative risk. The methodology handles limited data and subjective risk factors to help decision-makers minimize RTAs in Saudi Arabia and other jurisdictions.

14 Exploring factors contributing to Secondary Traumatic Stress in residents during a child maltreatment paediatrics rotation

Abstract Background Secondary Traumatic Stress (STS) refers to the distress and emotional disruption experienced by individuals caring for those who have experienced trauma. STS is increasingly recognised in child serving professions, especially in medical trainees and clinicians working in Child Maltreatment Paediatrics (CMP). Paediatric resident physicians are typically of younger age, work long hours in stressful conditions, and have limited CMP experience. This makes them particularly vulnerable to experiencing STS. In addition to affecting the wellbeing of trainees, STS can impede performance at work and affect patient care. Thus, it is important to understand and mitigate the development of STS among paediatric trainees during their CMP rotation. Objectives This study aims to identify key factors contributing to STS among medical residents at a tertiary care paediatric hospital during a CMP rotation. Design/Methods Qualitative interviews and focus groups were conducted to explore the experiences and perceptions of CMP trainees, staff physicians, and psychologists. Quality Improvement methods including a Fishbone diagram (figure 1), 5-whys analysis, and Pareto analysis (figure 2) were used to analyze the factors that contribute to residents developing STS symptoms. Results Our analysis revealed the following themes contributing to STS symptoms in paediatric residents: (1) limited awareness and education on STS symptoms, (2) lack of planned case debriefing, (3) residency-related burn out, (4) limited experience in CMP, (5) hidden curriculum of residency, and (6) limited opportunity to discuss STS symptoms. Conclusion Our study identified factors related to both limited knowledge around STS, and limited opportunities to debrief cases that may contribute to the development of STS among residents. These factors can, in part, be addressed on a program level. This aligns with existing STS literature which emphasizes implementing program level strategies to support professionals in addition to prioritizing self-care. Next steps involve implementing targeted interventions within the rotation to help mitigate STS effects on trainees.

Optimalisasi Kualitas Layanan Transportasi Publik: Pendekatan Model P-Transqual dalam Mengevaluasi Kinerja di PO. Moedah

Purpose: This study aims to quantify and scrutinize the caliber of public transportation services through meticulous application of the Public Transportation Quality (P-TRANSQUAL) framework. Research methodology: The proposed research method involves a qualitative approach that integrates the use of Public Transportation Service Quality (PTSQ) and fishbone diagrams. The research population consisted of users of PO Moedah services, selected randomly based on predetermined inclusion criteria, including diverse age groups, gender, occupation, and monthly income range. Results: The empirical findings suggest that, while functionally proficient, the public transportation services administered by PO Moedah are not immune to deficiencies, warranting remedial intervention. Limitations: The study was limited by subjective customer opinions and potential sample bias due to inclusion criteria such as age and income. Additionally, the findings are specific to PO Moedah's area and offer only a snapshot in time, limiting the generalizability and long-term relevance. Contribution: This study offers practical insights for PO Moedah to improve services and demonstrates the use of the P-TRANSQUAL framework to assess public-transportation quality. It highlights the importance of customer satisfaction and promotes sustainable urban transportation by addressing key issues, such as fuel consumption and traffic congestion.

Critical Value Reporting Performance Improvement Initiative: A Journey Towards Timely Patient Safety

Abstract Timely reporting of critical values serves as a quality indicator for the National Patient Safety Goal. Since the oncology inpatient unit at our institution has the highest number of critical values and often struggles to meet the targeted goal of timely results acknowledgement, this prompted a performance improvement initiative. By utilizing the Institute for Healthcare Improvement (IHI) Model for Improvement, the study aimed to decrease the time from specimen collection to acknowledgment of a complete blood count critical values (overall TAT). Three key metrics were monitored, including unit turnaround time (time from collection to receipt in laboratory; uTAT), laboratory turnaround time (time from receipt in laboratory to verified results) and timely critical value acknowledgment rate (% acknowledgement within 30 minutes). Quality improvement tools such as process maps and fishbone diagrams were employed, and two areas for improvement were identified. Firstly, it was observed that samples collected by the phlebotomists were delivered in batch to the laboratory via carts. However, samples collected by nurses were sent to the laboratory via a pneumatic tube. Hence, the uTAT varied drastically due to the different delivery methods. Secondly, the mode of alerting providers regarding critical values, which was via telephone calls from telecommunication staff, was deemed disruptive and redundant, as the providers often were already aware of the results from the electronic medical record (EPIC). Two multi-cycle Plan-Do-Study-Act (PDSA) interventions were implemented by a multidisciplinary team. The first focused on sending samples via pneumatic tube. The second PDSA intervention focused on a direct clinician acknowledgment of critical values within EPIC, by creating an auxiliary column on the EPIC patient list. Consequently, the overall TAT decreased from a median time of 167 minutes in July 2021 to 140 minutes by March 2022 in the oncology inpatient unit, with a sustained result (139 minutes) by October 2023. This reduction was driven by the standardization of pneumatic tube delivery system; the uTAT decreased from a median time of 104 minutes to 46 minutes by March 2022 and remained low at 52 minutes by January 2024. Notably, the rate of timely acknowledgment of critical value results worsened, dropping from 67% to as low as 51 % (March 2022) and improved to 64% by January 2024. It was realized that this unintended consequence was attributed to the decrease in uTAT, leading to more critical value results reported in early morning when there was less staffing. Despite the worsening in timely critical value acknowledgment, the overall TAT showed a discernible reduction. The application of IHI methodology played a pivotal role in expediting result reporting. Subsequent steps will focus on utilizing secure communication channels to augment the success rate of critical values acknowledgment within 30 minutes.

Improving Patient Wait Times on the First Day of Radiotherapy Treatment

Long wait times on starting day of radiotherapy (day 1) can cause dissatisfaction among both patients and healthcare providers. Reducing these wait times will decrease stress and decongest hospital facilities especially in current coronavirus disease 2019 times. A multidisciplinary core team was formed during the Stanford-India Collaborative Quality Improvement training to reduce the median wait times on day 1 of treatment from 6 to 4.5 hours (a 25% reduction). Several factors were identified on the fishbone diagram, and key causes were identified using a Pareto chart and action prioritization matrix. The Plan-Do-Study-Act Cycle strategy was undertaken for the identified interventions. The outcome measure was time from arrival at the hospital to entry into a treatment room. Data were obtained from time charts at various stations and electronic records. The secondary measures were visual analog scale (VAS) scores, 80th percentile wait times, and the day-2 delay percentage. The balancing measure was “new errors” due to interventions. The interventions included the completion of all administrative tasks not needing patients' presence on the day before day 1. Baseline data from 198 patients and postintervention data from 160 patients were compared and analyzed. The median wait time at baseline, which was 6 hours, was reduced to 4.2 hours. The VAS score showed 70.4, 67.7, and 71.9% satisfaction for the resident physician, therapists, and patients, respectively. The 80th percentile wait times reduced from 8 to 5.7 hours; and the day 2 starting rate decreased from 22.5 to 2.04%, with no new errors reported. Radiotherapy day 1 wait times can be safely decreased, leading to improved satisfaction among patients and healthcare providers, by utilizing classic quality improvement methods and tools.

Project management analysis-based on Shanghai Disney

This paper presents a comprehensive analysis of the project management strategies employed during the development of Shanghai Disneyland. It utilizes three key analytical tools: PESTLE, SWOT, and Fishbone Diagram, to assess various aspects of the project. The PESTLE analysis evaluates the external environment, including political, economic, social, technological, legal, and environmental factors, which influenced the park's successful completion. The SWOT analysis identifies the project's internal strengths and weaknesses, as well as the external opportunities and threats it faced. Additionally, the Fishbone Diagram highlights critical challenges, such as financing, technology, and localization, that contributed to delays in project progress. The findings of this study demonstrate how effective project management, supported by government partnerships and market demand, facilitated Shanghai Disneyland's establishment as a globally significant theme park. However, the paper also underscores the importance of addressing localization and financial sustainability to ensure long-term success. The analysis provides valuable insights into managing large-scale, culturally complex projects.

Understanding Isoniazid Crystals Agglomeration Through Quality by Design and Artificial Neural Network Analysis

Introduction: The aims of this study were to determine and govern critical sources of variability in the process and to investigate the effect of excipients and processing conditions on the critical quality attributes (CQAs) of isoniazid (INZ) crystal agglomerates using a quality-bydesign (QbD) paradigm along with risk-based approach. Methods: The QbD paradigm is thoroughly exercised to determine the CQAs and to, link these CQAs to agglomerate properties and to recognize potentially significant input variables. Considering this, a risk assessment tool was executed with different excipients and processing conditions to define their effect on CQAs of agglomerates. Potential risk factors were recognized using an Ishikawa diagram and then investigated using principal component analysis and an artificial neural network. After that, all agglomerates were optimized using the design of the experiment. Results: The optimized INZ crystal agglomerates were characterized using various tools such as X-ray diffractometry, Fourier transform infrared spectroscopy, scanning electron microscopy, differential scanning calorimetry, gas chromatography, and stability testing. These characterizations confirmed that INZ did not undergo any structural modifications in the agglomerates. Conclusion: The results indicate that the QbD principles and risk assessment tool provide a valuable means to fully understand directly compressible INZ crystal agglomerates, which could be considered an exceptional alternative to the granulation method.

Aplicación de la metodología MASP para reducir el tiempo de producción: el caso de una industria del mueble

The furniture industry generated sales of R$78 million in the year 2021. However, a company in the sector is not always able to deliver on time to fulfill. In this context, this research aimed to identify the main causes for the delay in delivery of orders in the company studied, applying the Methodology of analysis and problem solving (MASP) in order to identify, analyze and propose corrective actions. The study was conducted in the company Arte Mobília, which manufactures furniture for indoor and outdoor environments made of aluminum and sling fabric, whose delimitation was the process related to the production of chairs. As results, in the first stage of MASP the problem of the delay of orders that were delivered 10 days late was identified and in the second stage the family and the product to be studied, the chair 1, was identified. In the analysis stage quality tools were applied, such as brainstorming, Pareto chart, Ishikawa diagram, and the five whys. With the application of MASP it was possible to reduce the production lead time by 10 days. With this, the company will be able to present a higher level of service and be more connective in the market. ILIA: Investigaciones Latinoamericanas en Ingeniería y Arquitectura, No. 01, 2024: 146-154.

Streamlining process development and scale-up: Risk assessment to reduce workload in primary protein recovery

Risk assessment is an integral aspect of the Quality-by-Design strategy to identify potential obstacles at every stage of biopharmaceutical production, from process development to tech transfer. We explored flow process chart, root cause analysis, and failure mode and effects analysis, to assess the scale-up of bacterial cell disruption and its influence on centrifugation and filtration steps. The Ishikawa diagram suggests that data on the impact of homogenizer valve design on product release, impurity profile, particle size distribution, viscosity, and dsDNA fragment size are missing which were collected experimentally for this study. Cell lysates from micro-, lab- and pilot scales cell disruption were analyzed for the above-mentioned parameters. Process parameters affecting these output parameters were identified on each individual scale. Cell disruption on the micro scale was performed in a bead mill. High pressure homogenization was used on lab- and pilot scales. Cell disintegration by bead milling delivers homogenates of product and impurity content comparable to those on bench scale but with 3-fold higher viscosity and significantly larger dsDNA fragments, 8.0 instead of 1.0 kbp, respectively. Miniaturized pressure flow curves identified dsDNA fragment sizes as critical for filter performance during clarification. Combining risk assessment, micro scale cell disintegration and bench scale pressure flow curves allows for selective and efficient process development, and scale up for primary recovery steps.

A-088 Clinically Significant Errors Using the Diazyme Total Bile Acid Assay on the Roche c502 Analyzer: Investigating a Result Error Identifies a Novel Large-Scale Testing Error Caused by Reagent Carryover

Abstract Background Thoroughly investigating single patient result errors may identify systemic, large-scale testing errors. The laboratory observed an event where a revision to a Total Bile Acid (TBA, Diazyme Laboratories, Inc.) patient result following a 22S quality control (QC) failure displayed a larger than expected difference (52 to 5mcmol/L). TBA is primarily used for diagnosis and monitoring of intrahepatic cholestasis of pregnancy with results >10mcmol/L considered elevated. Retrospective review of result revisions following QC failures (3/15/2017-5/30/2023) revealed that 50%(20/40) yielded result differences of >10mcmol/L(>20SD based on assay imprecision). The aim of this study was to apply a systematic approach to i) estimate the rate of TBA errors, ii) ensure accurate result reporting during investigation period, iii) perform root cause analysis (RCA), and iv) determine corrective and preventative action(s). Methods Residual samples from TBA testing (6/24-7/5/2023) were retested(n=158), differences >+/-3.0mcmol/L or 15% were confirmed on an alternate analyzer, and reports were revised. Automated repeat testing of TBA samples >10mcmol/L was operationalized 7/6/2023. Initial and repeat TBA results were compared(n=448) and results differing by >+/-20% were remeasured on an alternate analyzer. RCA was conducted using a fishbone diagram. NaOH reagent probe washes were implemented for TBA and the error rate was re-assessed. Assays run prior to TBA samples with errors (n=15) were identified. To assess reagent carryover a residual serum pool (TBA ∼5mcmol/L) was aliquoted into 5 tubes in a sample rack. The first sample in the rack was programmed to run an assay suspected of causing carryover followed by 4 TBA measurements. Mean±standard deviation(SD) TBA concentrations were calculated. TBA was also measured in the liquid reagent for amylase, lipase, acetylcholinesterase (ACE) and fructosamine. Results Initial TBA retesting yielded no errors when initial TBA was ≤10mcmol/L(n=51). For samples with TBA >10mcmol/L(n=107), 9(8.4%) had differences exceeding criteria with 8/9 being revised to ≤10mcmol/L. Analysis of automated patient repeat data showed a 3.8%(17/448) error rate when initial TBA >10mcmol/L. After NaOH reagent probe washes were implemented, the error rate decreased to 0.7%(3/448). Assays run directly before an erroneously high TBA result included: lactate, fructosamine, soluble transferrin receptor(STFR), lipase, and ACE. A serum TBA pool(mean±SD=5.1±0.4 mcmol/L,n=15) measured 37.6±1.2mcmol/L(n=3) and 6.7±0.7mcmol/L(n=3) after lipase and fructosamine, respectively. No other assays demonstrated carryover. TBA in lipase reagent compartment B and C was 653 and 649mcmol/L, respectively, and 653mcmol/L in fructosamine reagent compartment B. Conclusions A single patient TBA result revision was investigated and led to identification of reagent carryover causing erroneously high TBA results on the Roche c502 analyzer. Automatic, real-time, repeat testing was implemented to prevent reporting incorrect patient results until RCA could identify the cause. Occurrence rate of erroneous high TBA results decreased from 3.8% to 0.7% after implementation of NaOH washes on the instruments. Carryover experiments confirmed that lipase and fructosamine assays cause carryover when run prior to a TBA sample due to measurable TBA in the reagent. The lab is pursuing moving the fructosamine and lipase reagent to the Roche Cobas c701 to prevent the issue.

Analisis Perancangan dan Kelayakan Pembukaan Apotek di Kabupaten Cirebon

Fajar Farma Pharmacy is a business operating in the health sector. Fajar Farma sells various health needs, such as medicines and health equipment. Currently, Fajar Farma Pharmacy already has one offline shop to sell its products. Because the income obtained in the last few years is quite satisfactory. To develop the pharmacy business, there are several solutions that can be used to solve problems. Depicted in the fishbone diagram there are 4 problem branches, namely man, facility, market, and method. Based on the problem branch, the solution that will be implemented is opening a new branch due to the existence of a market in Gunung Jati District. Therefore, the owner plans to open a branch shop of Fajar Farma Pharmacy which is located on Jalan Ki Gede Mayung, Gunung Jati District, Buyut Village, Cirebon Regency. In this research, a feasibility analysis was carried out covering 3 aspects, namely market aspects, technical aspects and financial aspects. After carrying out feasibility analysis calculations, the NPV value was IDR 63,638,483, the IRR was 40.61%, the payback period was 3.71 years or 44.55 months. So opening a new pharmacy branch can be said to be feasible. Based on sensitivity calculations, the increase in raw material prices is sensitive at 9.87%, the increase in labor costs is sensitive at 38.42%, while the decrease in demand is sensitive at 7.02%. The results of calculating the feasibility of opening a new branch of Fajar Farma Pharmacy with a MARR of 16.49% show that the NPV is still more than zero, the payback period is still within the investment period, namely 5 years, and the IRR is greater than MARR.

Optimizing access to care for new patients with cancer discharged from an observation unit.

119 Background: Each year, approximately 33,000 new cancer patients seek treatment at our dedicated cancer hospital, with many placed in our observation unit, the Clinical Decision Unit (CDU). These patients often experience significant delays in receiving oncologic care after discharge resulting in distress for both patients and providers. Our goal is to reduce the two-week appointment time from CDU discharge to outpatient oncologic care by more 10% for those eligible to be seen at the hospital. Methods: In fiscal year 2023, we gathered data on patients admitted to and discharged from the CDU, focusing on new patients. A multidisciplinary team developed a fishbone diagram, process flowcharts, and an impact matrix. Interventions included automated referrals, discharge notifications, patient and provider education, discharge booklets, and oncology recommendations for urgent consults. A physician satisfaction survey was conducted pre- and post-intervention. Three months of post-intervention data (February-May 2024) were reviewed, measuring the baseline percentage of patients receiving an appointment within two weeks, one month or more after CDU discharge. Results: In 2023, 90 eligible patients new to the institution were discharged from the CDU. Of those, 3 (3%) had follow-up appointments within 2 weeks, and 39 (43%) had appointments after 30 days or no appointment at all. Post-intervention data showed that out of 15 new patients discharged between February and May 2024, 10 (66%) had follow up appointments within 2 weeks, 4 (27%) within 30 days, while 1 (7%) had not yet received an appointment. Conclusions: Streamlining the referral process through a central service, automating the requests, and educating both providers and patients can reduce the time to establish oncologic care through an observation unit. However, limitations remain for patients with out-of-network insurance or lack of insurance coverage. Further research is necessary to assess whether expediting follow up cancer care for new patients improves clinical outcomes and relieves associated stress as we suspect it does. Time interval for new patients to acquire oncology clinic appointments post discharge. Dates/Time Frame Eligible New Patients with Appointments Within 2 weeks Eligible New Patients with Appointments within 15 to 30 days Eligible New Patients with No Appointment or Appointment > 30 days* Baseline DataFY 2023 3%(3/90) 53%(48/90) 43%(39/90) Post-Intervention:2/6/24 – 5/6/24 66%%(10/15) 27%(4/15) 7%(1/15) *Includes patients without follow up.

Optimizing infusion experience for patients in GI oncology at Hartford Hospital Cancer Institute.

331 Background: Cancer Treatments have become increasingly complex and the volume of patients requiring infusion treatments have increased in the outpatient setting. As a part of our Clinical Care Redesign Quality Initiative, the Hartford Healthcare Team identified that our GI Oncology patients receiving chemotherapy at the Hartford Hospital Infusion Center were experiencing a mean wait time of 81 minutes from the start of check-in to the start of their first medication, resulting in patient and staff dissatisfaction and inefficient use of resources. Our objective was to reduce the mean wait time to less than 60 minutes from the start of check-in to the start of the first medication by December 2023, which in turn would improve patient and staff satisfaction. Methods: By process mapping, creation of a fishbone diagram, and multi-voting, we demonstrated that waiting for laboratory results for patients who had provider and chemotherapy visits on the same day was a large contributor to long wait times. We implemented an Advanced Preparation Process that included Unlinking infusion visits from Provider visits and obtaining patient labs prior to chemotherapy treatment day to achieve the goal. Results: By Unlinking visits beginning mid-October 2023, we were able to decrease the mean wait time from 81 minutes to an average of 53 minutes, reflecting a 54% reduction in wait time. This allowed Pharmacy and Infusion Nurses additional time to review orders and complete safety checks and spend more time with patients at the chairside. An estimated amount of 12.6 hours of chair time was made available per week, representing a potential revenue increase of $188,021 annually. Most patients appreciated the decrease in wait time even if it meant coming in two separate days. Conclusions: The project aim of reducing wait times for GI Oncology patients was achieved. A reduction in time to first drug for other patients receiving chemotherapy during our pilot period was also noted, which we attributed to Hawthorne effect. Patient and staff satisfaction were improved. Our next steps will include continuing to optimizing the process.

A multisite initiative to assess the immunization status of medical oncology patients.

289 Background: The Swedish Cancer Institute (SCI) is committed to holistic care and recognizes immunizations are an essential component to quality outcomes. In 2022 the SCI was selected to participate in the Specialty Societies Advancing Adult Immunization (SSAAI) project supported by the Centers for Disease Control and Prevention (CDC) with a goal of incorporating the CDC Standards for Adult Immunization Practice into medical oncology clinical care. The CDC Standards for Adult Immunization Practice are assess, recommend, administer or refer, and document. Recognizing immunization status is not routinely assessed, this quality initiative aimed to increase assessment of immunization status in medical oncology across 7 network clinics on 4 campuses to above 50 % by the end of 2023. Methods: All team members completed the ASCO Quality Training Program. The Plan Do Study Act (PDSA) framework was selected. Assessment was defined as having completed the Immunization Activity Record within the Epic Medical Record system, which includes reconciliation with the Washington state immunization registry. Data was initially abstracted manually to determine the baseline assessment rate until an automated method was developed. A Fishbone diagram determined the top barrier was the lack of awareness about this functionality and lack of training around the task. A workflow diagram and standard operating procedure were implemented. Clinic staff were trained on the new workflow when rooming patients. A small pilot with one clinic of solid tumor medical oncology clinics was completed. Patients included were on active treatment and seen face to face within the clinic. The standardized process and tools were refined, and problem areas addressed. The work was then expanded to all seven of the SCI network medical oncology clinics including hematology as the final PDSA cycle using the same training, process and tools. Results: The Epic Immunization Activity Record completion rate went from less than 1% of solid tumor patients with an active systemic treatment plan to 61% in the pilot project. After two additional PDSA cycles to refine the steps and target problem areas, the rate improved to 67% over a 3-month period. The PDSA cycle was expanded to bring the refined process to all 7 network clinics with a baseline assessment rate of 6% which increased to 45% after interventions within a 3-month period and concluding the 2023 year. Conclusions: Developing tools and implementing a new workflow for immunization assessment yielded a significant improvement in assessment rates thereby setting a foundation of assessment utilizing the CDC Standards for Immunization Practice. The use of concrete written tools improves the sustainability of the changes. Additional tools and refinement of existing tools will be studied to improve the current rate and sustain the gains. Reference: Standards for Adult Immunization Practices | CDC .

Improving dihydropyrimidine dehydrogenase genotyping (DPYD) prior to initiation of fluoropyrimidine-based chemotherapy at a community-based hospital: A quality improvement initiative.

347 Background: Dihydropyrimidine dehydrogenase gene (DPYD) testing is crucial in preventing toxicities from fluoropyrimidine chemotherapy. Despite benefits and established guidelines, its adoption within healthcare organizations remains inconsistent and suboptimal. We implemented a quality improvement project to improve DPYD testing prior to fluoropyrimidine chemotherapy at a community-based hospital. We aimed to increase DPYD testing for patients receiving fluoropyrimidine-based chemotherapy from 65% to 95% between July 2023 to July 2024. Balancing measures included DPYD testing turnaround time. Methods: For baseline diagnostics, manual chart review was performed on 126 patients to identify frequency of DPYD testing, and turnaround time (TAT) between May 1, 2023 to August 4, 2023. Patients were excluded if they received fluoropyrimidine-based chemotherapy prior to May 1, 2023. A multidisciplinary team including medical oncology residents and staff, pharmacists, nurses, and clinical informatics specialists worked jointly to identify and address barriers to implementation. Barriers identified included lack of established workflows and awareness of the importance of testing. Diagnostic tools utilized included Ishikawa diagrams and process mapping. The team used Plan-Do-Study-Act (PDSA) cycles to address barriers. A p-chart was used to analyze the results. Results: The baseline DPYD testing rate was 65%. Barriers identified via multidisciplinary sessions included lack of established workflow, awareness and importance of testing. PDSA cycles included education sessions to breast medical oncologists and medical oncology nurses, and development of a best-practice advisory in the electronic medical record. The percentage of eligible patients receiving DPYD testing increased from 65% to 95.8% in the total population. For breast cancer patients, the rate increased from 16.7% to 100%. For gastrointestinal cancer patients, the rate increased from 56.1% to 94.2%. Sustainability was demonstrated two months post-intervention with TAT stable between 7-8 days. Conclusions: Through PDSA cycles, we improved the frequency of DPYD testing for patients receiving fluoropyrimidine chemotherapy from 65% to 95.8%. Future work will assess changes in chemotherapy prescribing behavior in the setting of variant DPYD results, and outcomes of patients with variant DPYD testing.

Analysis of Service Quality Improvement Using Service Quality (SERVQUAL) and Importance Performance Analysis (IPA) Methods (Case Study at PDAM Banggai Regency)

PDAM Kab.Banggai is a service company that has the aim of meeting the needs in the field of clean water must provide the best service. The purpose of this research is to analyze service quality based on customer satisfaction and find out the factors that affect service quality to get a solution to the causes of problems based on service quality. This research will use the servqual method to measure service quality with the level of perceptions and expectations of consumers in the services provided by service providers. Furthermore, the Importance Performance Analysis (IPA) method is used in measuring the level of importance and performance so that the company can find out the attributes that need to be improved and maintained in service based on a Cartesian diagram and will produce a basis for customer satisfaction. After that, the Fishbone Diagram is used to analyze the consequences by finding and describing the factors that cause the existing problems. Then given the proposed improvements and submitted PDAM to be followed up by PDAM Kab.Banggai. The results of the Service Quality analysis of the quality of service of PDAM Kab. Banggai obtained a negative Gap in the Reliability dimension at attribute B5 (-1.200), in the Responsiveness dimension obtained a negative Gap at attribute C1 (-1.140), at attribute C2 with a negative Gap (- 1.120) and in the Assurance dimension with a negative Gap (-0.560). The results of the analysis using Importance Performance Analysis obtained 4 attributes that are among the top priorities for improvement, namely the attributes contained in quadrant I. The four attributes that are the top priorities for improvement are the ease with which customers can submit complaints online to the PDAM, employees are responsive when answering complaints from customers through online media such as whatsapp, officers contact customers when they cannot fulfill the specified repair promise and the use of PDAM services Kab. Banggai is guaranteed to be safe when making payment transactions. The proposed improvements given to PDAM Kab. Banggai are Attribute D2, namely conducting a re- check before making payment bills to customers, collaborating with third parties such as banks and outlets (indomaret, alfamidi, etc.) and making payment applications directly linked to PDAM accounts so that there is no manipulation during the payment process. Attribute C2 is instilling a sense of responsibility in officers and openness to customers to contact customers as soon as possible if something happens or cannot fulfill the specified repair promise, the need to make SOPs so that they have standard provisions for contacting customers if they cannot fulfill repair promises and provide facilities to contact customers. Attribute C1, namely recruiting Customer Service and implementing a 24-hour work shift system to be available if there are complaints via messages or calls, implementing online complaint services for 24 hours to be responsive to answering customer complaints and providing social media accounts that are always updated to provide information about PDAM and responsive when there are complaints from customers online. Attribute B5, namely implementing a work shift system for officers who are available when there are complaints via messages or calls, implementing online complaint services through social media and providing media for customers to submit complaints online such as providing PDAM contact numbers that are always active 24 hours. For further research, it is hoped that it will be able to research to implement the proposed improvements provided and analyze the quality of service after implementing the proposed improvements provided by the author so that the effectiveness of the services that have been implemented can be known.

Development of intestinal colonic drug delivery systems for diverticular disease: A QbD approach

This study aimed to advance the development of intestinal colon-coated sustained-release matrix tablets of metronidazole for diverticulitis treatment, employing the Quality by Design (QbD) methodology. Comprehensive Risk analysis and Risk evaluation were conducted to assess the potential risks associated with Critical Material Attributes (CMA) and Critical Process Parameters (CPP). Ishikawa diagram, color-coded risk classification and the Risk Priority Number (RPN) were used as tools for risk evaluation. A Design of Experiments (DoE) was executed using a fractional factorial design, incorporating five key factors derived from the Risk analysis and Risk evaluation. Two levels and a central point were established for each factor, resulting in 28 batches of coated tablets. The manufacturing process involved direct compression, followed by a coating process using pH-dependent or time-dependent polymers. Characterization and dissolution studies were conducted on all batches, and the obtained results underwent analysis of variance (ANOVA).The findings demonstrated the robustness and reproducibility of both the direct compression and coating processes. Statistical analysis identified HPMC/chitosan ratio, blending time, coating polymer, and coating weight gain as factors significantly impacting drug release. A Design Space was established to delineate the interplay of these factors, offering insights into various combinations influencing drug release behavior. Thus, the design space for 10 % weight gain formulations includes a range of HPMC/CH ratios between 2.7–3 and mixing times between 10 and 12 min; for 20 % weight gain formulations it includes a range of HPMC/CH ratios up to 2 and mixing times between 10 and 16 min. Multiple Linear Regression between technological and biopharmaceutical variables were optimized facilitating scale-up operations. Batches with a 10 % weight increase and varied HPMC viscosity grades and coating polymers achieve ∼50 % drug release at 24 h; however, batches with a 20 % weight increase along, with either high proportions of HPMC and short blending times or low proportions of HPMC and longer blending times, achieve slow release of metronidazole. This study contributes to optimizing metronidazole colonic delivery systems, enhancing their potential efficacy in diverticulitis treatment.