Post on 20-Jan-2015
description
C&E Matrix
Identify contributing / causal factors of an adverse event
Anand Subramaniam
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“Experience is a hard teacher because she gives the test first, the lesson afterwards.”
- Vernon Sanders Law
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C & E – Focus
Focus on…Focus on…
Preventing adverse events and or recurrence, not blame
or punishment
Preventing adverse events and or recurrence, not blame
or punishment
Measuring and tracking
outcomes
Measuring and tracking
outcomes
Involving interdisciplinary teams and / or
those closest to and / or most
knowledgeable about the situation
Involving interdisciplinary teams and / or
those closest to and / or most
knowledgeable about the situation
System level vulnerabilities rather
than individual performance
System level vulnerabilities rather
than individual performance
Identifying contributing /
causal factors of an adverse event
Identifying contributing /
causal factors of an adverse event
C & E - Process Roadmap
Define the Effect
Define the Effect
Identify the Major
Categories (6M / 4P)
Identify the Major
Categories (6M / 4P)
Generate IdeasGenerate Ideas Evaluate IdeasEvaluate Ideas
Vote for the Most Likely
Causes
Vote for the Most Likely
Causes
Rank the Causes
Rank the Causes
Verify the Results
Verify the Results
Recommend Solutions
Recommend Solutions
C & E - Uses
Visual means for tracing a problem to its causes
Identifies all the possible causes of a problem and how they relate before deciding which ones to investigate
Is used as a starting point for investigating a problem
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C & E - Effect
The problem or quality characteristic
The effect is the outcome of the factors that affect it
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C & E - Matrix
Gain new knowledge and perspectives by sharing ideas with others
Assists in understanding the processes
Provides a basis for action Whenever a problem is discovered, using
C&E analysis forces one to take a proactive stance by seeking out causes
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C & E – KPIV / KPOV
C & E – Matrix (Worksheet) – Contd.
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Rating of Importance to
Customer
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Total
Process Step Process Input
1 02 03 04 05 06 07 08 09 0
10 011 012 013 014 015 016 017 018 019 020 0
0
Total 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lower Spec
Target
Upper Spec
List the process output
variables
List the process output
variables
Rate each output on a 1-to-10 scale, important to
VOC
Rate each output on a 1-to-10 scale, important to
VOC
Select the high ranking input variables to
start the FMEA process
Select the high ranking input variables to
start the FMEA process
Rate each input's relationship to
each output variable using a 0, 1, 3, 9 scale
Rate each input's relationship to
each output variable using a 0, 1, 3, 9 scale
List process input variables
(from the process map)
List process input variables
(from the process map)
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“Where facts are few, experts are many.”
- Donald R. Gannon