A l’hôpital, le bloc opératoire représente un environnement à risque pour le patient. La réalisation d’une chirurgie thyroïdienne demeure une tâche complexe dont le résultat dépend de la combinaison d’une multitude de facteurs qui demeurent mal connus. L’application des méthodes de contrôle qualité développées dans l’industrie peut être utile à leur découverte. Pendant quatre années, nous avons suivi la performance collective et individuelle d’une équipe chirurgicale à l’aide de cartes de contrôle. Des cartes de Shewhart et des cartes CUSUM ont été conçues pour analyser les variations des complications de la thyroïdectomie au cours du temps. Leur mise en place s’est accompagnée d’une réduction immédiate des hypocalcémies postopératoires, puis d’une stabilisation progressive des paralysies récurrentielles. La suractivité chirurgicale a été identifiée comme cause à l’origine d’une dégradation momentanée de la performance de l’équipe. Cette expérience de terrain a montré l’applicabilité des cartes de contrôle à la chirurgie thyroïdienne ainsi que leur intérêt pour aider les chirurgiens à interpréter la variabilité de leurs résultats et à maitriser les facteurs y concourant. Cependant, seules des actions concrètes destinées à améliorer la qualité de la prise en charge peuvent réduire la survenue de complications opératoires. Leur conception implique de mieux comprendre les facteurs influençant la performance du chirurgien et le travail en équipe au bloc opératoire pour garantir la sécurité du patient. / The operating room represents a high risk environment for the patient. Thyroid surgery remains a complex task whose outcome depends on the combination of poorly understood factors. Implementation of industrial quality control methods can be helpful in discovering them. For four years, we have monitored the individual and collective performance of a surgical team using control charts. Shewhart and CUSUM charts have been designed for analyzing the variations of thyroidectomy related complications over time. Their introduction immediately led to a reduction of postoperative hypocalcaemia, and then to a gradual stabilization of recurrent nerve palsy. The surgical overactivity was identified as a root cause of a temporary worsening of the team performance. This field study has shown the applicability of control charts in thyroid surgery and their value to assist surgeons in interpreting and controlling their results' variability. However, only concrete actions aiming at improving the quality of care may reduce the incidence of surgical complications. Designing these actions involves understanding the factors that influence the surgeon's performance and teamwork within operating room to ensure the patient safety.

Made available in DSpace on 2017-07-10T19:24:44Z (GMT). No. of bitstreams: 1 Eliane Hermes.pdf: 848736 bytes, checksum: 5c07576b6d2d54fb662b1b0b914ecc1b (MD5) Previous issue date: 2010-02-11 / Universidade Federal do Paraná / One of the factors that should be considered when purchasing an irrigation system is related to its application uniformity. It has a direct influence on agricultural productivity, which tends to increase with the improvement of this uniformity. The fertigation through drip irrigation system provides better application uniformity, therefore contributing to water and energy economy. The cassava wastewater provides a serious environmental problem when released directly into water bodies, and due to this, the application in the soil has shown beneficial effects when used in agriculture as organic fertilizer. Thus, the objective of this study was to evaluate four different treatments with six replicates each, considering two factors: hydraulic loading (1,0 and 1,5 m) and type of applied water: clean water and diluted cassava processing wastewater. The system was installed in the Experimental Center of Agricultural Engineering (NEEA), belonging to the State University of West of Paraná (UNIOESTE), in Cascavel - Paraná. Physicochemical characterization of water was performed to determine the clogging risk to the system by monitoring the parameters of pH, electrical conductivity (EC), dissolved solids (DS) and turbidity and determined the coefficients of flow variation (CV), emission uniformity (EU) and Christiansen Uniformity (CUC). In both treatments, with a hydraulic load of 1,5 m, 25 tests were performed in order to control statistical techniques and establishment of process capacity indices to the coefficients obtained. In treatments with cassava processing wastewater there was a decrease in the values of flow over time, with an average reduction of 20,02 and 18,84% for the hydraulic load of 1,0 and 1,5 m, respectively. The water used for irrigation in drip system showed pH values that can cause severe risk of clogging the equipment used. The quality of the diluted cassava processing wastewater used in the fertigation treatments had turbidity values outside the standards of CONAMA. The CV and the EU showed higher results in the treatment of irrigation with a hydraulic load of 1.5 m, being classified as excellent. Only the individual measures Shewhart chart of the CUC in the trials of fertigation was found in statistical control. The values of process capability indices showed a relationship with the coefficient of uniformity which are inversely proportional to CV and and directly proportional to EU and CUC. The process capability index was able to diagnose whether irrigation has the ability to maintain control and constant, or whether it will be able to maintain acceptable levels of uniformity. / Um dos fatores que devem ser considerados na aquisição de um equipamento de irrigação está relacionado à sua uniformidade de aplicação, pois ela influencia diretamente na produtividade agrícola, que tende a aumentar com a melhoria desta uniformidade. A fertigação por meio de um sistema de irrigação por gotejamento propicia uma melhor uniformidade de aplicação, promovendo a economia de água e energia. A água residuária de mandioca ocasiona um sério problema ambiental, quando lançada diretamente em corpos hídricos, porém sua aplicação no solo tem demonstrado efeitos benéficos, quando usada como adubo orgânico na agricultura. Deste modo, o objetivo deste estudo consistiu na avaliação da qualidade da irrigação e fertigação com água residuária de processamento de mandioca. O sistema foi instalado no Núcleo Experimental de Engenharia Agrícola (NEEA), pertencente à Universidade Estadual do Oeste do Paraná (UNIOESTE), no município de Cascavel Paraná. Foram realizados quatro tratamentos distintos com seis repetições cada, considerando-se dois fatores: carga hidráulica (1,0 e 1,5 m) e tipo de água aplicada: água tratada e água residuária de processamento de mandioca diluída. Foi realizada a caracterização físico-química das águas para verificar o risco de entupimento do sistema por meio do monitoramento dos parâmetros de pH, condutividade elétrica (CE), sólidos dissolvidos (SD) e turbidez e foram determinados os coeficientes de variação de vazão (CVQ), de uniformidade de emissão (UE) e de uniformidade de Christiansen (CUC). Nos dois tratamentos com carga hidráulica de 1,5 m foram realizados 25 ensaios para a utilização de técnicas de controle estatístico de qualidade e estabelecimento de índices de capacidade de processo dos coeficientes obtidos. Nos tratamentos com água residuária de processamento de mandioca houve um decréscimo nos valores de vazão ao longo do tempo, com redução média de 20,0 e 18,8% para a carga hidráulica de 1,0 e 1,5 m, respectivamente. A água utilizada para irrigação no sistema de gotejamento apresentou valores de pH que podem provocar risco severo de entupimento ao equipamento utilizado. A qualidade da água residuária de processamento de mandioca diluída utilizada nos tratamentos de fertigação obteve valores de turbidez fora dos padrões do CONAMA. O CVQ e UE apresentaram resultados mais elevados no tratamento de irrigação com carga hidráulica de 1,5 m, sendo classificados como excelente. Apenas o gráfico de medidas individuais de Shewhart do CUC nos ensaios de fertigação encontrou-se sob controle estatístico. Os valores dos índices de capacidade de processo apresentaram uma relação com os coeficientes de uniformidade inversamente proporcionais ao CVQ e diretamente proporcionais a UE e CUC. O índice de capacidade do processo mostrou-se capaz de diagnosticar se a irrigação tem capacidade de se manter sob controle e constante, ou seja, se será capaz de manter níveis aceitáveis de uniformidade.

Made available in DSpace on 2017-05-12T14:48:07Z (GMT). No. of bitstreams: 1 Eliane Hermes.pdf: 848736 bytes, checksum: 5c07576b6d2d54fb662b1b0b914ecc1b (MD5) Previous issue date: 2010-02-11 / Universidade Federal do Paraná / One of the factors that should be considered when purchasing an irrigation system is related to its application uniformity. It has a direct influence on agricultural productivity, which tends to increase with the improvement of this uniformity. The fertigation through drip irrigation system provides better application uniformity, therefore contributing to water and energy economy. The cassava wastewater provides a serious environmental problem when released directly into water bodies, and due to this, the application in the soil has shown beneficial effects when used in agriculture as organic fertilizer. Thus, the objective of this study was to evaluate four different treatments with six replicates each, considering two factors: hydraulic loading (1,0 and 1,5 m) and type of applied water: clean water and diluted cassava processing wastewater. The system was installed in the Experimental Center of Agricultural Engineering (NEEA), belonging to the State University of West of Paraná (UNIOESTE), in Cascavel - Paraná. Physicochemical characterization of water was performed to determine the clogging risk to the system by monitoring the parameters of pH, electrical conductivity (EC), dissolved solids (DS) and turbidity and determined the coefficients of flow variation (CV), emission uniformity (EU) and Christiansen Uniformity (CUC). In both treatments, with a hydraulic load of 1,5 m, 25 tests were performed in order to control statistical techniques and establishment of process capacity indices to the coefficients obtained. In treatments with cassava processing wastewater there was a decrease in the values of flow over time, with an average reduction of 20,02 and 18,84% for the hydraulic load of 1,0 and 1,5 m, respectively. The water used for irrigation in drip system showed pH values that can cause severe risk of clogging the equipment used. The quality of the diluted cassava processing wastewater used in the fertigation treatments had turbidity values outside the standards of CONAMA. The CV and the EU showed higher results in the treatment of irrigation with a hydraulic load of 1.5 m, being classified as excellent. Only the individual measures Shewhart chart of the CUC in the trials of fertigation was found in statistical control. The values of process capability indices showed a relationship with the coefficient of uniformity which are inversely proportional to CV and and directly proportional to EU and CUC. The process capability index was able to diagnose whether irrigation has the ability to maintain control and constant, or whether it will be able to maintain acceptable levels of uniformity. / Um dos fatores que devem ser considerados na aquisição de um equipamento de irrigação está relacionado à sua uniformidade de aplicação, pois ela influencia diretamente na produtividade agrícola, que tende a aumentar com a melhoria desta uniformidade. A fertigação por meio de um sistema de irrigação por gotejamento propicia uma melhor uniformidade de aplicação, promovendo a economia de água e energia. A água residuária de mandioca ocasiona um sério problema ambiental, quando lançada diretamente em corpos hídricos, porém sua aplicação no solo tem demonstrado efeitos benéficos, quando usada como adubo orgânico na agricultura. Deste modo, o objetivo deste estudo consistiu na avaliação da qualidade da irrigação e fertigação com água residuária de processamento de mandioca. O sistema foi instalado no Núcleo Experimental de Engenharia Agrícola (NEEA), pertencente à Universidade Estadual do Oeste do Paraná (UNIOESTE), no município de Cascavel Paraná. Foram realizados quatro tratamentos distintos com seis repetições cada, considerando-se dois fatores: carga hidráulica (1,0 e 1,5 m) e tipo de água aplicada: água tratada e água residuária de processamento de mandioca diluída. Foi realizada a caracterização físico-química das águas para verificar o risco de entupimento do sistema por meio do monitoramento dos parâmetros de pH, condutividade elétrica (CE), sólidos dissolvidos (SD) e turbidez e foram determinados os coeficientes de variação de vazão (CVQ), de uniformidade de emissão (UE) e de uniformidade de Christiansen (CUC). Nos dois tratamentos com carga hidráulica de 1,5 m foram realizados 25 ensaios para a utilização de técnicas de controle estatístico de qualidade e estabelecimento de índices de capacidade de processo dos coeficientes obtidos. Nos tratamentos com água residuária de processamento de mandioca houve um decréscimo nos valores de vazão ao longo do tempo, com redução média de 20,0 e 18,8% para a carga hidráulica de 1,0 e 1,5 m, respectivamente. A água utilizada para irrigação no sistema de gotejamento apresentou valores de pH que podem provocar risco severo de entupimento ao equipamento utilizado. A qualidade da água residuária de processamento de mandioca diluída utilizada nos tratamentos de fertigação obteve valores de turbidez fora dos padrões do CONAMA. O CVQ e UE apresentaram resultados mais elevados no tratamento de irrigação com carga hidráulica de 1,5 m, sendo classificados como excelente. Apenas o gráfico de medidas individuais de Shewhart do CUC nos ensaios de fertigação encontrou-se sob controle estatístico. Os valores dos índices de capacidade de processo apresentaram uma relação com os coeficientes de uniformidade inversamente proporcionais ao CVQ e diretamente proporcionais a UE e CUC. O índice de capacidade do processo mostrou-se capaz de diagnosticar se a irrigação tem capacidade de se manter sob controle e constante, ou seja, se será capaz de manter níveis aceitáveis de uniformidade.

隨著經濟不斷的發展，企業間的競爭也愈趨激烈，因此在以利潤最大、付出成本最小的前提下，一些可能造成成本增加的因素就不能不重視。在量測產品的特性所使用的量測機器，可能因為量測設備的不精確造成誤差，進而影響測量產品品質特性的實際值。是以量測儀器測量產品特性時的誤差對於管制圖的設計參數的影響及使用管制圖監控製程的能力是我們所關切的課題。 本文探討量測誤差對 — 管制圖的效應。運用George Tagaras非對稱管制圖的概念，及同時考慮Taguchi的損失函數和測量誤差下，以更新理論方法建立 — 管制圖，並推導出目標函數，再透過最佳化的技巧以決定 — 管制圖的最佳經濟設計參數值。另外討論管制圖在統計層面的表現，並與經濟設計的結果作比較。 在資料分析方面，本研究考慮32組製程和成本參數組合，透過最佳化技巧找出 — 經濟及經濟統計管制圖之最小單位時間平均成本及最佳設計參數組合。再利用敏感度分析，觀察量測誤差對設計參數的影響，另外得知重要的製程和成本參數為何。這些可作為製程工程師決策參考之用。

在子製程相關下所產生的品質特性資料使Shewhart管制圖無法對各別的製程狀態加以解釋，而選控圖可診斷前後製程的責任歸屬。本文提出有n個子製程時，建立選控圖的方法及在製程上之應用，以追蹤製程變異之發生，明確地劃分出子製程的責任歸屬。文中並以模擬資料和實際例證說明，在相關品質特性的資料中，選控圖的建立及診斷效果。在實務上，若產品是由許多相關的子製程共同製造而成時，對於受到前製程影響的品質特性，即可用選控圖進行管制，以獲得正確的製程狀態訊息，並進一步採取正確的管制行動。

最近三十年來,最佳經濟設計管制圖已被考慮用來維持製程的穩定.由於在 實務上■管制圖被廣泛使用,是以大多數管制圖經濟模型的發展,都以單一 非機遇因素下的■管制圖為研究對象,但在實務上製程常會受二個或二個 以上非機遇因素的干擾.是以本研究利用更新理論方法建立二個非機遇因 素成本模式.又為使成本模式包含顧客的聲音以顯示品質的重要,本研究提 出以產品出廠後對社會的損失替代傳統上的成本考量.當推導出能反應顧 客滿意度的二個非機遇因素製程成本模式後,藉著最佳化技巧可決定■管 制圖的最佳設計參數值,並由例子的分析說明模式參數對最佳設計參數值 的影響 .另外,■經濟管制圖與Shewhart■管制圖間的成本比較顯現前者 能有顯著改善.最後,在考慮損失函數下■管制圖的建立與應用將被舉例說 明.

Many performance measurement algorithms can only evaluate measure active managers' performance after a period of operating time. However, most investors are interested in monitoring the active managers' performances at any time, especially, when the performance is going down. So that the investors can adjust the targets and contents of their portfolios to reduce their risks. Yashchin,Thomas and David (1997) proposed to use a statistical quality control (SQC) procedure to monitor active managers' performances. In particular, they established the IR (Information Ratio) control charts under normality assumption to monitor the dynamic performances of active managers. However, the distributions of IR statistic usually possess fat tail property. Since the underlying distribution of IR is an important hypothesis in building up the control chart, we consider the heavy tail distributions, such as mixture normal and generalized error distribution to fit the IR data. Based on the fitted distribution, the IR control charts are rebuilt. By simulations and empirical studies, the remedial control charts are found to detect the shifts of active managers' performances more sensitively.

Count data are often encountered in manufacturing and service industries due to ease of data collection. These counts can be useful in process monitoring to detect shifts of a process from an in-control state to various out-of-control states. It is usually assumed that the observations are independent and identically distributed. However, in practice, observations may be autocorrelated and this may adversely affect the performance of the control charts developed under the assumption of independence. In this thesis, the cumulative sum (CUSUM) control chart for monitoring autocorrelated processes of counts is investigated. To describe the autocorrelation structure of counts, a Poisson integer-valued autoregressive moving average model of order 1, Poisson INAR(1), is employed. Changes in the process mean in both positive and negative directions are taken into account while designing the CUSUM chart. A trivariate Markov Chain approach is utilized for evaluating the performance of the chart.

With the globalization era, software companies around the world not only have to face competition in the domestic industry, as well as the subsequent challenge of large international companies. For this reason, domestic software companies must to upgrade their own software quality. Domestic government agencies and non-governmental units together promote Capability Maturity Model Integration (CMMI). Hope to improve their quality of software development process through internationalized professional evaluation. Towards the high-maturity software development process, software development process should be estimated quantitatively in CMMI Level 4. There are frequently used statistical process control (SPC) methods, including control charts, fishbone diagram, pareto charts ... and other related practices. Its goal is to maintain stability of overall software development process, so the output performance can be expected. Primitive SPC applied in manufacturing industry, successfully improving the quality of their products. But some characteristics of software, such as software development is human-intensive and innovative activities. It increases not only variability of control, but also difficulties of implementation. In this study, collate and analyze the operational framework of SPC and CMMI Level 4 through study of literature and case study with the case company-A company's practices. It contains two points, one is organization point of view, the other is methodological point of view. Organizational point of view includes stage of CMMI Level 4 and SPC implemented in the software industry, as well as how to design the organizational structure. Methodological point of view includes the steps to run SPC¡Buseful methods and tools. Methodological point of view also uses control theory to collate relevant control mechanisms. Finally, we illustrate how to integrate SPC into the company's system development life cycle. The framework can provide a reference for domestic software companies of longing for implementing CMMI Level 4 and SPC.

Statistisk processtyrning, SPS, är ett välkänt verktyg som används för kvalitetsförbättringar inom organisationer världen över. De senaste åren har tillverkande organisationer tenderat att gå mot kortare serier, vilket medför en problematik när de vill tillämpa statistiska metoder som är utvecklade för traditionell masstillverkning. Framgångsfaktorer för implementering av SPS vid små serier är ett relativt outforskat område och kräver därför ytterligare forskning. Syftet med denna studie var att ta fram en modell över hur SPS framgångsrikt kan implementeras av organisationer med små serier och en stor detaljflora. För att besvara syftet genomfördes en fallstudie med både kvantitativ och kvalitativ metod. Deltagande observationer och en workshop med 15 deltagare utfördes för att identifiera existerande variationer samt definiera nuläget i det avgränsade produktionsflödet, vars processer studerades i studien. Tre produktfamiljer och kritiska parametrar som representerade produktkvalitén valdes ut för att följas upp i styrdiagram. En mätsystemanalys utfördes för att undersöka om de mätdon som i stor utsträckning användes för kvalitetskontroll i processen var tillförlitliga. Styrdiagram upprättades anpassade för små serier och statistiska analyser utfördes för att undersöka om SPS var en användbar metod för kvalitetsförbättringar i processer med små serier. En kvalitativ benchmark med fyra deltagande organisationer utfördes även för att ta del av deras erfarenheter relaterat till implementering och arbete med SPS.  Resultatet visade att den studerade organisationen behöver utföra förändringar gällande arbetsmetoder för kvalitetskontroll samt hantering av processer och mätsystem. Det finns även behov av ett omfattande förbättringsarbete, för att eliminera det flertalet orsaker till systematiska variationer som identifierades påverka processerna och produktkvalitén. Dessa förändringar krävs innan en implementering av SPS kan genomföras. Verktyg inom SPS visade sig med framgång kunna användas för att förbättra processer med små serier, vid användning av standardiserade styrdiagram som möjliggör analys av flera produkter i samma diagram. Processer med små serier och en stor detaljflora medför en utökad komplexitet vid statistiska analyser och visar tecken på ett flertal svårigheter som ökar risken för en fallerad implementering.  Utifrån analyser av det kvalitativa och kvantitativa resultatet skapades en modell med 15 framgångsfaktorer för implementering av SPS vid små serier. Faktorerna bör följas av organisationer med små serier som vill lyckas med att implementera SPS. Framgångsfaktorerna är följande: (1) Var beredd på en kulturförändring som kräver att SPS vävs in i hela organisationen, (2) Förmedla ett tydligt mål och hållbar strategi för arbetet med SPS, (3) Skapa ett utbrett engagemang i hela organisationen, (4) Utse en SPS-koordinator, (5) Inför utbildning och uppföljning från start, (6) Skapa tvärfunktionella team, (7) Främja samarbete och delaktighet under förbättringsarbetet, (8) Ställ krav på ett dugligt mätsystem, (9) Utför en pilotstudie där det finns intresse, (10) Identifiera kritiska processer, produktfamiljer och parametrar, (11) Börja med att lära känna processerna, (12) Upprätta standardiserade styrdiagram, (13) Tolkning och analys av styrdiagram utförs enligt Montgomerys metod för statistiska analyser, (14) Sträva efter stabila processer, (15) Utför kontinuerlig uppföljning. / Statistical process control, SPC, is a widely used technique for quality improvements by companies all over the world. The current trend in manufacturing organizations is directed towards shorter productions runs, which cause problems when applying traditional statistical methods developed for SPC on mass production runs. The critical factors for a successful implementation of SPC on short runs are still not fully explored and require further research. The main purpose of this study was to present a conceptual framework that illustrates the successful implementation of SPC in organizations with short runs and extensive product portfolio. In order to answer the research questions, a case study research methodology with both quantitative and qualitative methods was used. Participant observations and a workshop including 15 participators were performed in order to identify existing process variability’s and current state of the studied production processes.  Three product families and key quality characteristics of each product were chosen to be monitored in control charts, based on scrap costs and staff experiences of the production process.  A measurement system analysis was used to determine if the gauges, used to make measurement quality controls, were capable. Control charts were constructed and adjusted to short production runs. Statistical analysis was then made on the information gathered through the control charts to determine if statistical tools within SPC was useful for quality improvements on short production runs.  Also a qualitative benchmark was performed with four manufacturing companies to take part of their experiences and knowledge related to the implementation and application of SPC.  The findings indicate that the studied organization needs to improve working methods related to quality inspections and monitoring of the production processes. The organization also needs to improve the measurement system and make an extensive work of improvement to reduce the many identified special causes of variation that affects the processes and product quality, before implementing SPC in the organization. Findings showed that SPC tools and techniques successfully can be adopted to improve short run production processes when using standardized control charts for different product types. Short run production processes involve more complex statistical analysis which could inhibit the success of an implementation of SPC.   The analysis of the qualitative and quantitative findings resulted in a framework including 15 critical success factors for the implementation of SPC in short production runs. All the following critical success factors should be taken into account by organizations with short runs that aspire a successful implementation of SPC: (1) Be ready to make a cultural change including the recognition of the importance of SPC within the whole organization, (2) Communicate a clear goal and long-term strategy, (3) Create motivation and commitment from top management to operators on the shop floor, (4) Select a SPC coordinator, (5) Introduce a training programme with feedback from start, (6) Create cross-functional teams, (7) Stimulate cooperation and participation within the work of improvements, (8) Ensure a capable measurement system, (9) Perform a pilot project with enthusiastic employees, (10) Identify critical processes, product families and key quality characteristics, (11) Focus on exploring process behaviors, (12) Construct standardized control charts, (13) Interpret and analyze control charts according to Montgomery’s method for statistical analysis, (14) Attempt to obtain processes in control, (15) Perform continuous follow ups.