Fishbone Diagram Research Articles

Increase The Percentage of Coal Conservation Deposited in ROM Drainage Areas

The research aims to increase the conservation percentage of trapped coal in the ROM A1 drainage area from February to June 2024 by improving fine coal management and adding value to the conservation of PJP. This study also seeks to reduce penalties from fine coal blending into sellable products and minimize environmental pollution in the ROM A1 area. The study employs a descriptive method, focusing on implementing coal conservation in drainage areas by determining the scope of each conservation object. Root cause analysis using a Fishbone diagram was used to identify key improvement strategies for increasing coal conservation percentages. Initial observations in the ROM A1 drainage area revealed 6,829 tons of unpreserved fine coal, primarily due to rainwater runoff. The results showed that with proper implementation of conservation techniques, including the installation of fine coal traps and the centralization of fine coal in collection points, the conservation rate improved from 0% to 62% by April 2024. In tangible terms, 83 tons of fine coal, worth IDR 26,434,928, were saved, contributing to both environmental conservation efforts and economic benefits for the company. This study highlights the importance of continuous coal conservation efforts, especially in mining operations where environmental and financial impacts can be significant.

The Relevance of Agrarian Reform to the Sustainable Development Goals: Analysis of Community Land Empowerment for Food Sufficiency and Gender Equality through the Fishbone Diagram Method

Abstract: This study aims to examine the state of food sufficiency and gender equality in Purwabakti Village and the relevance of community land empowerment programs in achieving food sufficiency and gender equality. The research follows a qualitative case study approach, collecting data through interviews, observations, and document analysis. Data were analyzed qualitatively using the fishbone diagram method, focusing on four primary variables: human resources, machinery, methods, and materials. Data on malnutrition and stunting indicate that issues of food vulnerability compromise food sufficiency in Purwabakti Village. Furthermore, gender equality remains a challenge within this predominantly patriarchal society. Women tend to fulfill traditional gender roles with domestic responsibilities, while men assume public roles. This patriarchal rural society generally accepts the predominant land ownership by men (as heads of households), reflecting gender inequality. The fishbone diagram analysis indicates that, despite some progress, community land empowerment programs still exhibit limitations in addressing the SDGs, particularly the goals of “zero hunger” and gender equality. Keywords: Access regulation, Rural Communities, Gender inequality, Patriarchal Culture, Woman Empowerment

THE IMPORTANCE OF ROOT CAUSES IN SOLVING PROBLEMS IN THE AUTOMOTIVE INDUSTRY

A key element of any quality management system is continuous improvement and a systematic approach to managing non-conformances. The aim of this paper is to use selected statistical methods and quality control techniques to present a way in which an organisation can achieve quality improvement. The 8D methodology was used to solve the observed front grid problem on the bumper of a Porsche Cayenne using a structured eight-step Plan-Do-Check-Act (PDCA) approach to problem solving. As this was an important customer originating from Dubai, it was imperative to immediately start solving the issue that arose with the ACC grid on the front bumper, the problem identified was an existing cut-out in the radar grid. Using the 8D methodology and supporting tools such as the Ishikawa diagram or 5Why, the root cause of the problem was identified and permanent corrective actions were planned and implemented as recommended in the 8D report to reduce the likelihood of the problem recurring and increase customer satisfaction.

QLTI-21. STREAMLINING THE STUDY INTAKE PROCESS AT THE CANCER CLINICAL AND TRANSLATIONAL RESEARCH OFFICE (CCTRO)

Abstract Challenges in the Protocol Intake/Activation process at the Henry Ford Cancer Center, particularly during the budget negotiation and coverage analysis (CA) phases, hamper operational efficiency and financial prospects. This study aimed to improve budget time and process efficiency. Process flow mapping, Value Stream Mapping (VSM), and cause-effect analysis using a fishbone diagram were used to identify and analyze key bottlenecks, focusing on the budget negotiation and CA phases. Budget negotiation took an average of 121.5 days in 2023 due to multiple procedures and a lack of standardized practices. Delays ranged from 127.75 days in August to a low of 69.84 days in November of 2023. The budget build process averaged 13.31 days, with an additional 7.57 days for approval, totaling 20.89 days. The CA phase had an average cycle time of 10.82 days (range 2-10 days). To improve approval times, it was recommended to implement an Electronic Document Management System to automate routing, signing, and tracking of budget and CA-related documents, standardized budget templates to streamline negotiations, a detailed electronic checklist to streamline task lists for document collection and budget negotiation, automated reminders for internal and external stakeholders to ensure timely submission of necessary documents, and timely submission policies enforced by a dedicated finance member on committees. Newly developed Key Performance Indicators (KPIs) such as ‘time to collect documents,’ ‘time between committees,’ and ‘time for budget negotiation process,’ along with a dual tracking system in Excel, were proposed to monitor and improve these metrics. The recommendations are expected to significantly enhance the efficiency of the Protocol Intake/Activation process. By reducing the budget negotiation phase to less than 60 days and optimizing the CA process, faster study initiation, better resource utilization, and improved responsiveness to research opportunities will be achieved. This study underscores the critical need to address operational challenges in clinical trial management to enhance CCTRO’s capability to conduct timely and effective research.

Can the Manufacturing Process Be Improved by FMEA? A Study on X Company in Plastic Packaging Industry in Vietnam

This study based on the FMEA method, provides a systematic approach, which include identifying potential errors in the production process, tracking priority issues, proposing improvement solutions, and putting those solutions into practice in order to improve the flexible plastic packaging manufacturing process at a typical X company in the plastic packaging industry in Vietnam. It is found that four large errors – GP8, SM4, LM4, and BF4 – stand out as having an RPN index higher than 250. The aforementioned issues are also analyzed, and their root causes are tracked down using techniques like brainstorming, cause-effect diagram, and 5 Whys. Then, appropriate actions are taken to deal with these causes. Overall, the findings can serve as an insightful reference for Vietnamese manufacturing companies using the FMEA method to identify any potential errors in their production processes. After that, the company is able to organize proper inquiries and make recommendations for potential failure prevention strategies as well.

Risk assessment through feature, event, and process for repurposing suspended oil and gas wells for geothermal purposes

Many countries have set the goal of net zero carbon emission and are diverting their energy source towards renewables. In that respect, geothermal energy is a continuous renewable energy source that is not affected by any metrological conditions. However, geothermal energy is not used to its full potential, and at present, less than 1 % of renewable energy is produced by geothermal sources. One of the biggest reasons that hinder its adoption is the cost of drilling and completion associated with the geothermal well, which almost takes 50 % of the project budget. Therefore, it is important that, where possible (with conducive geothermal conditions), conventional oil and gas wells that are old or temporarily suspended should be retrofitted into geothermal wells. In this way, the initial cost of the geothermal project can be reduced, which is mainly due to the drilling operations. However, before repurposing old retired wells, conducting a proper risk assessment is important to avoid any well integrity issues in the long run. Therefore, this paper presents a concept of accessing the risk using Feature, Event, and Process (FEP) that have been integrated with the interaction matrix, incident potential matrix (IPM), and cause-effect plot diagram. This risk assessment technique identifies the well components that might be susceptible to failure, and remedial work should be conducted on such elements. However, geothermal wells have no specific FEPs; hence, the FEPs from CCS wells have been used, which have their limitation when used for geothermal systems. Nonetheless, to show the feasibility of this approach in assessing the risk, two case studies of the fictitious tubingless geothermal well are presented in this paper.

Optimization Parameters for PLA Through Additive Manufacturing: Taking Mixed Shapes as an Example

In recent years, additive manufacturing has been widely used in industrial, medical, and educational fields. Material extrusion is used in most industries to increase development efficiency and reduce costs. This study used the material extrusion to discuss the print quality of additive manufacturing and optimized the processing parameters based on material properties. Based on the literature, this study summarized the fishbone diagram influencing printing quality. The layer height, nozzle temperature, printing speed, infill pattern, and filling spacing were selected as the control factors of the Taguchi method. An orthogonal array L16 was used for parameter design. The optimal parameters were analyzed using the variance and the response surface method. The results of the study are as follows.

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).

QbD decorated ellagic acid loaded polymeric nanoparticles: Factors influencing desolvation method and preliminary evaluations

Polymeric nanoparticles are one of the emerging drug delivery systems in the field of oncology. Ellagic acid is a polyphenolic compound with vast effects like anti-cancer, anti-viral, and anti-oxidant. The ellagic acid nanoparticles was prepared by desolvation method. Formulating ellagic acid NPs using BSA enhances the stability and solubility of ellagic acid. Quality by design (QbD) based approach was adopted to improve the final quality and effectiveness of the formulation. The Critical quality attribute (CQAs) was defined and risk assessment was performed with the help of the Ishikawa fishbone diagram. Solubility analysis was done for the drug with methanol, ethanol, water, and acetone. Preliminary studies were performed to study the effect of type of desolvating agent, the concentration of polymer the pH of the polymer solution, amount of desolvating agent on the particle size and entrapment efficiency of the nanoparticles. A greater quantity of desolvating agent results in a narrower particle size because of thorough desolvation, and the increased encapsulation efficiency is linked to reduced protein-protein interactions. Desolvation process can cause the protein to gradually change structure, form clumps, and eventually form nanoparticles, so might be its shows increase in entrapment efficiency. A desolvating agent volume of 4 ml resulted in a particle size of 1724 ± 1.27 nm. When the amount of desolvating agent was increased to 6 ml and 8 ml, the particle size decreased to 160 ± 0.66 nm and 218 ± 0.47 nm, respectively. Fourier Transform Infrared Spectroscopy (FTIR) data showed no incompatibilities were observed between drug and polymer. In-vitro dissolution showed the nanoparticles may follow the control release pattern over 24 hours. All the formulated batches of zeta potential were found to be in the range −30 mV to +30 mV which indicated good colloidal stability of the NPs and the PDI value ranging from 0.18 to 2.8. The higher drug encapsulation of the drug was more than 50 % which gives higher drug release at a site of action and in-vitro drug release of more than 80 % may improve the dosage frequency. The in vitro drug release data was also studied by various kinetic models. The in vitro drug release analysis shows sustained release of drug from nanoparticles and follow Korsmeyer-Peppas model. All these findings were in good agreement which may open a new gateway for future research in the field of oral oncology.

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.