1. C&E Matrix Identify contributing / causal factors of an adverse event Anand Subramaniam

3. C & E – Focus Focus on… Preventing adverse events and or recurrence, not blame or punishment Measuring and tracking outcomes Involving interdisciplinary teams and / or those closest to and / or most knowledgeable about the situation System level vulnerabilities rather than individual performance Identifying contributing / causal factors of an adverse event

4. C & E - Process Roadmap Define the Effect Identify the Major Categories (6M / 4P) Generate Ideas Evaluate Ideas Vote for the Most Likely Causes Rank the Causes Verify the Results Recommend Solutions

8. C & E – KPIV / KPOV

9. C & E – Matrix (Worksheet) – Contd. List the process output variables Rate each output on a 1-to-10 scale, important to VOC 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 List process input variables (from the process map)