A solução de problemas é parte fundamental da manutenção da qualidade e da melhoria contínua. Ao longo dos anos diversos métodos foram desenvolvidos para solucionar problemas, todavia nem todos os métodos são aplicáveis em todos os problemas ou adequados para todos os setores. Caracterizado pelo ambiente em constante mudança, o setor hospitalar possui problemas complexos, cuja solução necessita de uma abordagem adequada e robusta. Dessa forma, o presente trabalho objetiva avaliar o desempenho de três métodos normalmente utilizados para solução de problemas: A3, RCA e FRAM, quando aplicados em ambiente hospitalar. Para esse fim, os três métodos foram aplicados no mesmo processo, de prescrição e medicação, de um hospital universitário. Os resultados das aplicações foram analisados de acordo com os critérios: número total de ações de melhoria propostas, dificuldade de implementação, a possibilidade de replicação das ações entre as unidades do hospital, o tempo necessário para aplicação dos métodos, o número de envolvidos, a necessidade de capacitação da equipe e um indicador de prioridade das ações propostas. Além disso, a percepção dos profissionais da saúde em relação aos métodos foi analisada. Os resultados demonstram que, no contexto avaliado, os métodos apresentaram um bom desempenho, por terem apresentado melhorias que, em média, foram consideradas adequadas pela instituição. / Problem solving is a fundamental part for quality maintenance and continuous improvement. Through the years many methods were developed to solve problems, though these methods do not apply to every problem, or are suitable to every type of activity. Kwon for its constant changing nature, hospitals have complex problems, which need a suitable and robust approach to solve. Thus, the present study has the objective of evaluating the performance of three methods usually used for problem solving: A3, RCA and FRAM, when applied on a hospital. For this, the three methods were applied in the same process, of prescription and medication, in an academic hospital. The results were analyzed accordingly to the following criteria: the total number of improvement actions proposed, implementation difficult, replication possibility along the departments of the hospital, the time needed to apply the methods, the number of people involved, the need of training for the team and an indicator for prioritization. Besides that, the health sector workers’ perception regards the methods was analyzed. The results evidence that, in the studied context, the methods had good performance, because introduced improvements that, on average, were considered suitable for the institution.

Sistemas de saúde têm sido cada vez mais exigidos a serem mais eficientes, o que encorajou o uso de iniciativas de melhoria de processos. A partir de então, a Produção Enxuta (PE) surgiu como uma abordagem amplamente utilizada. Alguns resultados insatisfatórios da PE podem ser, parcialmente, explicados pela falta de considerar a complexidade dos serviços de saúde. Os sistemas de saúde são classificados como sistemas sócio-técnicos complexos (SSTC) devido à incerteza, diversidade e interações não-lineares. De acordo com a literatura, as implementações de Lean em serviços de saúde geralmente envolvem Kaizen, que tende a produzir ganhos significativos de eficiência e segurança através de mudanças relativamente pequenas e localizadas. Contudo, as melhorias locais podem implicar resultados globais indesejados, uma vez que as interações entre os elementos de sistemas complexos podem não ser lineares. Para isso, este trabalho desenvolve e aplica uma framework que visa avaliar projetos de melhoria em SSTC. O estudo foi realizado em uma unidade de internação de um hospital escola. As interações entre os projetos foram modeladas através do desenvolvimento de um diagrama de loop causal, o qual representou variáveis relacionadas a cinco projetos de melhoria analisados e um modelo FRAM. Os projetos também foram avaliados quanto ao seu impacto no sistema e sua adesão a boas práticas em Kaizen, identificadas na literatura. A framework demonstrou-se eficaz em elencar as variáveis para que possam influenciar positivamente os resultados dos projetos e embasar recomendações para a condução de novos projetos de melhoria por meio de uma visão sistêmica. / Healthcare systems have been increasingly demanded to be more efficient, which has encouraged the use of process improvement initiatives. From these, lean production has emerged as a widely used approach. Some disappointing results of lean production can be partially due to the lack of consideration of the complexity of healthcare. Health systems are classified as Complex socio-technical systems (CSTS) due to the uncertainty, diversity, and non-linear interactions. According to the literature, the implementation of Lean in healthcare usually involves Kaizen, which tends to produce significant gains in efficiency and safety through relatively small and localized changes. However, local improvements may imply unwanted overall results, since interactions between elements of complex systems may not be linear. For this, this work develops and applies a framework that aims to evaluate improvement projects in CSTC. The study was performed in an in-patient surgical ward of a teaching hospital. The interactions between the projects were modelled through the development of a causal-loop diagram, which accounted for variables related to all five projects, and a FRAM model. The projects were also evaluated as to their impact on the system and their adherence to good Kaizen practices identified in the literature. The framework proved to be effective in highlighting the variables so that they can positively influence the projects results and support recommendations for conducting new improvement projects through a systemic view.

The Vessel Traffic Service (VTS) is a complex system tasked with ensuring the safety of navigation within specified areas known as VTS areas. Earlier research in the domain has often focused on the decision support systems and other tools employed by the VTS operators to provide the vessels in the area with VTS services. Consequently, less effort has gone into looking at the system itself and the human factors aspects of the system. This study uses the Functional Resonance Analysis Method (FRAM) to create a functional model of the VTS. It looks at how a VTS works, what the different components are and how these components are related. The main purpose of the FRAM model is to serve as a basis for future application by identifying the functions that constitute the system, and to illuminate the potential variability therein. To demonstrate how it might be used, an instantiation of an observed scenario will be presented. A structural description of the VTS is also presented, which aims to serve as an introduction to the domain for readers who are previously unfamiliar with it. The functional model shows that a lot of the potential variability seems to lie in the functions that rely heavily on human interaction, which is to be expected, as human performance is highly variable. It also shows that the availability and reliability of relevant information is crucial in order to be able to provide the VTS services, and if the information for some reason is unavailable or insufficient it seems likely to cause variability.

付記する学位プログラム名: デザイン学大学院連携プログラム / 京都大学 / 0048 / 新制・課程博士 / 博士(工学) / 甲第22772号 / 工博第4771号 / 新制||工||1746(附属図書館) / 京都大学大学院工学研究科機械理工学専攻 / (主査)教授 椹木 哲夫, 教授 松原 厚, 教授 小森 雅晴 / 学位規則第4条第1項該当 / Doctor of Philosophy (Engineering) / Kyoto University / DFAM

Forskning visar att motivation är betydelsefullt för elevers inlärningsprocess och skolresultat. Med detta som utgångspunkt är syftet med denna underesökning att undersöka vilka orsaker som finns till bristande motivation hos eleverna i samband med modersmålsundervisningen samt vad lärare kan göra för att höja elevernas motivation i deltagandet av modrsmålsundervisningen. Denna kvalitativa studie utgår från sju intervjuer. Tre intervjuer av modersmålslärare och sju intervjuer med elever i högstadiet. Ur intervjuerna med lärare och elever framkom att de faktorer som påverkade elevens motivation var klassrumsklimat, schemat, relationer till omgivningen, gruppindelning och samarbetet mellan modersmålsläraren med övriga lärare inom andra skolämne. / Research has shown that motivation is of great importance for the individual student's learning process and school results. The purpose of the degree project is to investigate the causes of lack of motivation in students who participate in mother tongue teaching and what teachers can do to stimulate this lack of motivation. In a qualitative study, a number of interviews were conducted. On the one hand, three mother tongue teachers in the subjects Arabic, Dari and Polish were interviewed, and on the other hand students from year 6 to year 9. The interviews asked questions about what perceptions students have about their mother tongue, what teachers can do about lack of motivation and what framework factors effect teachers' attitudes. To learn the mother tongue. The results showed that students lack of motivation was due to various factors, including lack of time, work environment, less inclusion of the mother tongue subject, mother tongue teachers relätionship to teachers in other school subject. The conclusion we reached showed the mother tongue subject's role in the diversity ofh the school community, by strengthening the student's identity and personality, and we found som tips on measures for lack of motivation among students and teachers for the subject's mother tongue.

Methods for testing commercial off-the-shelf (COTS) digital devices at varying levels of complexity is presented and discussed as well as the results for testing a COTS SRAM, FRAM, and SoC using these methodologies in a pulsed dose rate environment at Little Mountain Test Facility (LMTF) and neutron testing at Los Alamos Neutron Science Center (LANSCE). Investigations at LMTF revealed a dependence in all three devices on the integrated dose of a single pulse of radiation, implying that the duration of radiation plays a significant role in the response. The test infrastructure necessary to dynamically access an FRAM at LMTF and time the access with the pulse of radiation allowed for the discovery of a new FRAM failure mode where an entire word of the FRAM becomes corrupted as well as selecting between two different failure modes based on the timing of the pulse. A novel component-based testing methodology for testing complicated SoCs is presented and used to report on the cross-sections of several components on the Xilinx MPSoC, including its DMA which has not previously been reported.

Fjärrvärme är den vanligaste uppvärmningsformen i Sverige och mer än hälften av alla lokaler och bostäder får sin uppvärmning från gemensamma fjärrvärmeanläggningar. Rökgaskondensering producerar 11 % av all fjärrvärme vilket gör den till den tredje största fjärrvärmeproducenten i Sverige. Det är därför är det viktig att den är så effektiv som möjligt. För att öka effektiviteten i förbränningsanläggningar i fjärrvärmesystem kan rökgaskondensering installeras i sammanband med de flesta bränslen som avger fuktig ånga. Rökgaskondenseringen har en viktig roll i samhället då den tar vara på energi som annars skulle gå förlorad samtidigt som den kan rena avgaserna från förorenade utsläpp. Borlänge‑Energi äger ett rökgaskondenseringssystem på Stora Enso Kvarnsvedens Pappersbruk. De vill nu utreda om deras rökgaskondenseringssystem körs så effektivt som den skulle kunna göra. Den här rapporten undersöker därför hur driften påverkas av förändrade fram- och returledningstemperaturer samt vad produktionskostnadsförändringarna på den producerade värme blir. Beräkningar har genomförts med hjälp av fjärrvärmevattnets densitet, specifikvärmekapacitet, flödes- och temperaturskillnad i Excel. Alla beräkningar har utgått från medianvärdet för månaden och sedan jämförts med vad som händer vid förändrad fram‑ och returledningstemperatur. Som underlag för beräkningarna har data insamlad under perioden januari 2015 och december 2018 använts. Resultatet visar att öka framledningstemperaturen till 95 °C från medianframledningstemperaturerna för respektive månad, det vill säga från temperaturintervall på 79 – 88 °C till 95 °C, ökar energikostnaderna med cirka 2,5 miljoner SEK per år. Kostnaden kan minskas med 400 000 SEK/år genom att sänka returledningstemperaturen till 40 °C. Minskas istället framledningstemperaturen till 75 °C när utomhustemperaturen är varmare än ‑1 °C, minskar de nuvarande energikostnaderna. En minskad framledningstemperatur ger även minskade förluster i ledningarna, minskat slitage, minskad bränsleförbrukning och minskade utsläpp. Temperatursänkning till 75 °C från temperaturintervallet 79 – 88 °C kan minska kostnaderna med 620 000 SEK per år. Skulle returledningstemperaturen sänkas men framledningstemperaturen bibehållas som den är idag kan en kostnadsminskning på över 400 000 SEK nås. Genom att sänka både fram- och returledningstemperaturerna kan en kostnadssparning på över 1 miljon SEK per år ske. Den framledningstemperatur som rekommenderas att Borlänge‑Energi strävar efter är: 75 °C när utomhustemperaturen är varmare än -1 °C 80 °C mellan -2 och -4 °C 85 °C vid -5 °C 90 °C mellan -6 och ‑7 °C 95 °C mellan -8 och -11 °C / The most common way of heating buildings in Sweden is by district heating, more than half of all the locales and homes is heated this way. Flue gas condensation is the third largest contributor of energy in district heating at 11 %. The importance of its efficiency is thereby big. Flue gas condensation can be installed at combustion boilers to increase the efficiency, it can be used in combination with most fuels that exhaust steam. The flue gas condensation has an important role by harnessing the energy in flue gases and cleansing it from environmental hazards. The flue gas condensation unit on Stora Enso Kvarnsveden Mill is owned by Borlänge‑Energi. They want to know if the condenser is operating as effective as it could be. This report investigates how the condenser and external heater at Stora Enso Kvarnsveden Mill is affected by different supply and return temperatures as well as what the production costs of the energy is. The calculations have been accomplished by using the density, specific heat capacity, flow- and temperature differences in Excel. All the calculations have originated from the median value for each month and used in comparison. The basis of the calculations is data that has been collected in the period of January 2015 to December 2018. The results indicate that increasing the supply temperature to 95 °C increases the energy costs by about 2 500 000 SEK per year. These costs can be reduced by 400 000 SEK per year by decreasing the return temperature to 40 °C. If the supply temperature is instead decreased to 75 °C when the temperature outside is higher than -1 °C, the costs decreases. A low supply temperature leads to less wear on the pipes, less heat losses, less fuel consumption and less emissions. This temperature reduction can decrease the costs by 620 000 SEK per year. If the return temperature is reduced but the supply temperature retained as it is today the costs could decrease by over 400 000 SEK per year. And by reducing both the supply and return temperature a cost saving of over 1 000 000 SEK per year could be achieved. The recommendation is therefore a lowering of the supply temperature to 75 °C when the temperature outside is warmer than -1 °C. The recommended supply temperature is: 75 °C when the temperature outside is warmer than -1 °C 80 °C between -2 and -4 °C 85 °C at -5 °C, 90 °C between -6 and ‑7 °C 95 °C between -8 and -11 °C

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.