Assignment_Week 6_Control

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Hutchinson Community College *

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601

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Mechanical Engineering

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Feb 20, 2024

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Week 6 Assignment – Control Task Points Possible 1. Mistake Proofing 10 2. Updated FMEA 10 3. Standard Operating Procedures 10 4. Control Plan 20 5. Control Charts 30 6. Process Monitoring Communication 20 1. Mistake Proofing – Your Lean Six Sigma team is seeking to reduce the incidence of ventilator associated pneumonia by ensuring the head of the patient’s bed is elevated between 30° and 45°. Describe a detection and prevention approach that could be used to solve this problem, then score each of them with the solution priority number scale provided in the presentation. a. Detection Approach – One possible detection approach to ensure the head of the patient's bed is elevated between 30° and 45° is by implementing an automated monitoring system. This system could consist of sensors or electronic devices that continuously measure and monitor the angle of the bed. The sensors would be programmed to detect any deviations from the desired range (30°-45°) and trigger an alert or notification to the healthcare staff. Solution Priority Number (SPN) Scale: To assign a score to this detection approach, we can use a solution priority number scale that evaluates various factors such as impact, feasibility, and resources required. Assuming a scale from 1 to 10, with 1 being the lowest priority and 10 being the highest, the score for this detection approach could be: Impact: The impact of implementing an automated monitoring system would be relatively high, as it would help detect and prevent incidences of ventilator-associated pneumonia. Score: 8 Feasibility: Depending on the availability of technology and resources, implementing an automated monitoring system may have different levels of feasibility. Score: 6 Resources Required: The implementation of an automated monitoring system would require an initial investment in sensors, devices, and software, as well as training for healthcare staff. Ongoing maintenance and support would also be necessary. Score: 7 Overall SPN: The overall solution priority number for this detection approach could be 7.3 (average of the scores). b. Prevention Approach – A prevention approach to ensure the head of the patient's bed is elevated between 30° and 45° could involve the use of physical restraints or positioning aids. These aids could be designed to keep the patient's head in the desired position and prevent unintentional movement or slippage. Solution Priority Number (SPN) Scale: Similar to the detection approach, we can evaluate the prevention approach using the SPN scale: Impact: The impact of using physical restraints or positioning aids would be moderate, as it can help maintain the desired head elevation and reduce the risk of ventilator-associated pneumonia. Score: 6

Feasibility: Implementing physical restraints or positioning aids may require training for healthcare staff and ensuring patient comfort and safety. Score: 7 Resources Required: The resources required for this prevention approach would primarily involve the procurement of appropriate physical restraints or positioning aids, along with any necessary training and maintenance. Score: 6 Overall SPN: The overall solution priority number for this prevention approach could be 6.3 (average of the scores). 2. Updated Failure Modes and Effects Analysis - Insert the first nine steps of the FMEA which you completed in prior modules into the table below and complete the remaining rows. Process Step Identifying areas of improvement in medical care processes and practices. Potential Failure Overlooking critical areas for improvement Potential Failure Effect Missed opportunities for enhancing care Severity 8 Potential Cause of Failure Unclear criteria for identifying improvement areas. Occurrence Likelihood 5 Current Control Regular performance reviews and feedback system Detection Low visibility of improvement opportunities Risk Priority Number 40 (Severity * Occurrence * Detection) Recommended Action Develop clear criteria for identifying improvement areas Who and When? Project Team Action Completed Occurrence Likelihood 4 Detection 6 Risk Priority Number 192 3. Standard Operating Procedures – write an SOP for the process described in question 2 above. Standard Operating Procedure (SOP) for Improving Medical Care and Attention 1. Purpose: The purpose of this Standard Operating Procedure (SOP) is to outline the process for improving medical care and attention within the organization. This SOP aims to address patient complaints, enhance patient satisfaction, and ensure a patient-centric approach throughout the healthcare delivery process. 2. Scope: This SOP applies to all healthcare personnel involved in providing medical care and attention, including but not limited to doctors, nurses, support staff, and administrators. 3. Responsibilities: 3.1. Project Team: - Develop and implement improvement strategies. - Identify areas for enhancement based on patient complaints. - Execute recommended actions. - Monitor progress and evaluate outcomes. 3.2. Healthcare Personnel: - Adhere to the revised protocols, guidelines, and practices. - Report any issues or observations related to medical care and attention. - Participate in training programs and performance reviews.

4. Process Steps: 4.1. Identifying Improvement Areas: a. Review patient complaints and feedback collected through surveys, complaint forms, and other feedback channels. b. Analyze common themes and patterns in patient complaints. c. Identify specific areas of improvement, such as inadequate identification procedures, insufficient post- surgical care, short and unsatisfactory doctor appointments, delayed response to urgent situations, unprofessional behavior from healthcare professionals, and discomfort during exams. d. Document the identified improvement areas for further action. 4.2. Developing Improvement Strategies: a. Form a project team responsible for developing improvement strategies. b. Collaborate with relevant stakeholders, including healthcare personnel and patient representatives, to gather insights and perspectives. c. Conduct root cause analysis to identify the underlying causes of the identified issues. d. Brainstorm and develop targeted interventions, protocols, and guidelines to address the identified improvement areas. e. Ensure that the improvement strategies align with the organization's goals and values. 4.3. Implementing Improvement Strategies: a. Communicate the revised protocols, guidelines, and practices to all healthcare personnel through training sessions, workshops, and written documentation. b. Provide necessary resources and support to implement the improvement strategies effectively. c. Monitor and evaluate the adoption and adherence to the revised protocols and practices. d. Address any challenges or barriers to implementation promptly and effectively. 4.4. Monitoring and Evaluation: a. Establish performance indicators and metrics to measure the effectiveness of the improvement strategies. b. Regularly monitor and evaluate patient satisfaction scores, patient complaints, and patient outcomes. c. Collect feedback from healthcare personnel regarding the impact of the implemented changes. d. Conduct periodic performance reviews to assess the progress and identify areas for further improvement. 5. Documentation: All relevant documentation, including patient complaints, improvement strategies, protocols, training materials, and performance evaluation reports, should be appropriately documented and maintained for future reference and continuous improvement purposes. 6. Revision and Continuous Improvement: This SOP should be reviewed periodically to ensure its effectiveness and relevance. Any necessary revisions should be made based on the evaluation of the improvement strategies and changing organizational requirements. 7. Training and Awareness: All healthcare personnel should receive appropriate training on this SOP to ensure their understanding and compliance. Regular awareness programs can be conducted to reinforce the importance of providing improved medical care and attention. 8. References: List any relevant references, guidelines, or standards that support the implementation of this SOP. 9. Approval: This SOP is approved by [Name and Position] and is effective from [Effective Date].

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4. Control Plan – develop a control plan using the table below for the process described in question 2 above. Add or delete rows as needed. Issue Timing Measure Trigger Owner Corrective Action Process Adjustment Overlooking critical areas for improvement Before identification Review patient complaints and feedback Completion of patient complaint review Project Team Develop clear criteria for identifying improvement areas Revise identification criteria accordingly Inadequate post-surgical care During post- surgical care Post-surgical care checklist Completion of post-surgical care Healthcare Personnel Implement comprehensive post-surgical care protocols Update post- surgical care checklist and protocols Short and unsatisfactory doctor appointments During doctor appointments Patient feedback surveys Low patient satisfaction scores Healthcare Personnel Enhance appointment scheduling and communication processes Improve appointment scheduling system and communication protocols Delayed response to urgent situations During urgent situations Response time measuremen t Exceeding defined response time Healthcare Personnel Implement escalation procedures for urgent situations Train staff on escalation procedures and establish clear communication channels Unprofessiona l behavior from healthcare professionals Ongoing monitoring Patient feedback and staff observations Reports of unprofessional behavior Healthcare Personnel Conduct regular professionalism training and reinforce organizational values Reinforce code of conduct and values through training and performance evaluations Discomfort during exams During exams Patient feedback and observations Reports of patient discomfort Healthcare Personnel Improve communication and patient comfort measures during exams Train staff on effective communication and implement comfort measures during exams 5. Control Charts – follow the steps outlined in Chapter 17 of the text beginning on page 247 to create the charts listed below using the “Control Module Data” excel document posted in blackboard. The tabs at the bottom of the excel sheet contain the data for the charts below. Make sure to include your name in the title of each chart and paste an image of the chart in the appropriate section below. a. Bar Chart –

3D Chart b. Stacked Bar Chart –

c. Pie Chart – d. Scatter Diagram –

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e. X-Bar Control Chart (include Mean, UCL, LCL, and SD lines as displayed in the presentation) 6. Process Monitoring Communication – create a process monitoring communication tool for the process you described in question 2 above. Potential options include scheduling boards, Takt boards, issue boards, Kanban Cards, or Check Sheets.