organized structure(understaffed, wrong procedures, overwhelming patients), culture unsupportive of patient safety, physicians intolerance of uncertainty, health care professions fears( liability)
asks if anything needs to be changed, CEO gives opportunity to give feedback
work around the problem instead of fixing it
Forcing function Constraining function- deliberate pause Redundancy function- double check (med admin) Normalizing of deviance- acceptance of work around Diffusion of responsibility- no on is in charge, is this good or bad
confidentiality focus on the whole story emphasis on near misses sharing knowledge
what is epidemiology
study of diseases- how, when or where risk and protective factors contagious diseases and non- transmissible dieseases
factors that mask the real effects, make things worse, -age is a confounding factor
RR is the risk of an event relative to exposure. It is a ratio of the probability of the event occurring in the exposed group versus a non-exposed group. ( hazard ratio)
is favored for case controlled studies and retrospective studies.
types of errors
Judgement error- did it but wrong decision Execution error- right decisions but did it wrong Error of omission- didn't' do it Error of commission- shouldn't have done it but did it anyway
near patient, last layer of defense
away from patients, poor design, easiest to fix
5 Lean principles
establish a high agreement of what and how, systematic waste elimination, systematic problem solving, observe work activities connections and flows, create a learning oragnization
A shoe manufacturing firm learned through a Lean Six Sigma project their boot soles could be made of a different material requiring two less steps in the process. Removal of these two steps yielded a monthly cost savings of $7,500. Therefore the reported financial savings for this LSS project were _____________.
A Belt utilized a diamond symbol in a Process Map she created for the process that was subject to her LSS project. By use of the diamond symbol she was showing a(n) _______________ point in the process
. When in the process of trying to identify the Critical X's for a LSS project a Belt creates a(n) _____________ because frequently it is 20% of the inputs that have an 80% impact on the output.
When a Belt is developing a Macro Process Map to define a complex process he will frequently include activities across various department to capture all the appropriate activity. He will use _____________ to show which department is responsible for which steps in the process.
This formula is used to calculate a Z score that, with the appropriate table, can tell a Belt what ____________________________________.
proprtion of data is between X and U
As we calibrate our Measurement System to assure accurate data we frequently encounter Bias which is the __________________ of a measured value from the ________________ value.
In an "X" Sifting exercises a Belt will use a(n) _______________ to assist in isolating families of variation that may exist within a subgroup, between subgroups or vary over time..
Multi- Vari Chart
. When analyzing sample data a Belt may experience a Bimodal Distribution with each mode displaying Normal Distribution. This could be caused by __________________________ .
a. Two different machines being read b. Two operators on different shifts c. Two suppliers parts being used ****d. All these are correct answers******
A battery manufacturer was considering changing suppliers for a particular part. The purchasing manager required that the average cost of the part be less than or equal to $32 in order to stay within budget. A sample of the 32 initial deliveries had a Mean of the new product upgrade price of $28 with an estimated Standard Deviation of $3. Based on the data provided, the Z value for the data assuming a Normal Distribution is?
When conducting Hypothesis Analysis a Belt must use the formula shown to determine if a certain value is between - 1 and + 1 which will lead to a conclusion relative to the hypothesis. The value calculated by this formula is the ________________________ .
d. Sample Correlation Coefficient
. When doing a graphical analysis of DOE results a Belt frequently uses the Main Effects Plot. To determine the relative impact of a variety of inputs on the output of interest it is easy to identify the most impactful input because the slope of the line on the Main Effects Plot is __________________.
A ____________________ is used to create a model of the affect on an output by the variation in two or more of the inputs.
A Belt has used the 5S approach of Lean to set up a control method with frequently used tools organized as shown in this graphic. The Belt has applied the ______________ principle of 5S.
In the Control Phase of a LSS project a Belt will identify key metrics that can be monitored and analyzed to give an indication that a process may be moving towards an out of spec condition. When he applies this approach he is using __________________.
Statiscial process control
As a Belt completes a LSS project she creates for the Process Owner a Control Plan. The ________________ portion of the Control Plan details the actions to be taken when the KPI's indicate they may be moving outside acceptable limits.