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

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Good Luckhttp://www.linkedin.com/in/anandsubramaniam