HIS (LAB) - CTC

BSMT - O1C
MISSION AND VISION - It is a business's guiding image of success.
- "Destiny is not a matter of chance, but of choice.
Mission statement - Not something to wish for, but to attain.
- is a role, or purpose, by which an organization
intends to serve its stakeholders. Why do we need it?
- It describes what the organization does (current - Vision statement is a tool to inspire and provide
capabilities), who it serves (stakeholders), and a sense of direction and purpose.
what makes the organization unique - A vision provides the fabric for working together
(justification for existence). and accomplishing our goals.
- always exist at the top level of an organization, - A good vision statement will help when there are
but may also be set for different organizational no clear answers, or for critical decisions that
levels or components. will fundamentally impact your products or
- simply an organization's reason for existing. services.
- Control your destiny or someone else will!
What does it do?
- It tells a company's stories and ideals in less What makes a good vision statement?
than 30 seconds. - It would be short, simple and powerful.
- It provides the focus on the main business - Remember a vision is meant to inspire, has an
- activities emotional impact.
- If it is written well, it can help reduce "clutter" in - It must give a clear direction or mental image to
other documents and processes. anyone that reads it.
- It can be described as "The best way to make a - Provide a sense of belonging to the
fire with two sticks is to make sure one of them stakeholders. "We provide the world's builders"
is a match.
Examples of visions
For developing missions of any project or 1. McDonald's - We are committed To doing what is
organization, the following two questions' answers right. To being a good neighbour and partner in the
should be written: community To conduct our business with the
1. What are we going to do? environment in mind
2. How are we going to do it 2. Ford - our company delivers excellent products
and services and strives to make the world a better
Examples of mission statement place.
Farm fresh company -
To become the number one produce store in Main Difference between mission and vision
Street by selling the highest quality, freshest farm ● mission statement: describes the *present*
produce, from farm to customer in under 24 hours state of a person or organization: "Who are you?
on 75% of our range and with 98% customer Why are you here? Why do you exist?"
satisfaction ● vision statement describes *future* state: "Who
do I want to be? Where do we want to go?" The
How to write mission statement? vision should be inspirational and slightly out of
Write down your ideas for why you need mission reach. Typically, it is a person or organization's
statement for your company. vision that provides a framework for planning.
This is your dream, the thought of success over the
next 5 to 10 years. Objectives
This is the emotion. After developing mission statement, objectives are
This the path or goal we all must meet. required to define. Objectives are much specific than
"Knowledge is limited. Imagination encircles the mission statement
world". For example- I want to finish my assignment by 10
o'clock this morning. This indicates to perform a
Vision statement number of tasks including typing text into computer,
- Vision statement identifies where the reviewing some questions/criteria that have already
organization intends to be in the future or where be written, printing out the assignment for
it should be to best meet the needs of proofreading and so on.
stakeholders.
- Incorporates a shared understanding of the Objectives must be evaluated by SMARTER tool:
nature and purpose of the organization and uses ● Specific
this understanding to move the organization ● Measurable
toward a greater purpose.

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● Attainable
● Realistic
● Timeframe
● Extending
● Rewarding
Goal
● A target to achieve within a specific time.
Without a goal or aim, you cannot live (lead)
your life happily and with the feeling of
satisfaction.
● Can be one or more objectives that need to be
achieved by a specific time.
● Makes one to get clarification to do a specific
task choosing from various options what one
thinks of about his future
Types of goals
● Uniform goals
○ A single goal is set for all organizations
within the Company.
○ Every organization is expected to meet the
same goal.
● Performance based goals
○ Every organization is given a goal that
reflects an increment on last year's
performance
○ Increments are chosen to represent equal
effort for organizations at different starting
points
● Potential based goals
○ Criteria (external and/or internal) are used
to assess organization's potential
○ Based on criteria of a model or ratings,
goals are set by the criteria
○ Goal = f (criterion)
Core competencies
● The objective of the strategic planning process is
to assess the core competencies of a company
● Core competencies are a set of unique internal
skills processes and system provide competitive
advantage in the market.
● A company should list functions, activities and
skills that add values to both products and
services better than competitors.
● For example, one function such as research,
distribution, marketing or selling can add value
to a product and this function needs to be
improved continuously to stay ahead than other
competitors
● Can be defined as the unique combination of the
resources and experiences of a particular firm. It
takes time to build these core competencies and
they are difficult to imitate. Critical to sustaining
these core competencies are their:
○ Durability - their life span is longer than
individual product or technology life-cycles,
as are the life spans of resources used to
generate them, including people.
○ Intransparency - it is difficult for
competitors to imitate these competencies
quickly.
○ Immobility - these capabilities and
resources are difficult to transfer.
HEALTH SYSTEM
HEALTH SYSTEM (WHO, 2007)
Consists of all organizations, people and actions
whose primary intent is to restore or maintain
health.
Includes efforts to influence determinants of health
as well as more direct health-improving activities.
It is MORE than the pyramid of publicly owned
facilities that deliver personal services.
Guiding values and principles
● Values and goals enshrined in the Alma Ata
declaration.
● WHO’s commitment to gender and human
rights.
● World Health Report of 2000
Health Systems Goals:
● Overall Outcomes (World Health Report 2000):
○ Improving health and health equity through
ways that are:
■ Responsive
■ Financially fair
■ Best or most efficient use of available
resources
● Intermediate Goals:
○ Greater access to and coverage for effective
health interventions
○ Provider quality and safety are not
compromised
WHO Building Blocks for Health
SERVICE DELIVERY
- Good health services are those which
deliver effective, safe, quality personal and
non-personal health interventions to those

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that need them, when and where needed,
with minimum waste of resources.
HEALTH WORKFORCE
- A well-performing health workforce is one that
works in ways that are responsive, fair and
efficient to achieve the best health outcomes
possible, given available resources and
circumstances (i.e. there are sufficient staff,
fairly distributed; they are competent,
responsive and productive).
INFORMATION
- A well-functioning health information system is
one that ensures the production, analysis,
dissemination and use of reliable and timely
information on health determinants, health
system performance and health status.
MEDICAL PRODUCTS, VACCINES, & TECHNOLOGIES
- A well-functioning health system ensures
equitable access to essential medical products,
vaccines and technologies of assured quality,
safety, efficacy and cost-effectiveness, and their
scientifically sound and cost-effective use.
FINANCING
- A good health financing system raises adequate
funds for health, in ways that ensure people can
use needed services, and are protected from
financial catastrophe or impoverishment
associated with having to pay for them. It
provides incentives for providers and users to
be efficient.
LEADERSHIP/GOVERNANCE
- Leadership and governance involves ensuring
strategic policy frameworks exist and are
combined with effective oversight, coalition
building, regulation, attention to system-design
and accountability.
The Department of Health (DOH)
Mandate (E.O. No. 119, Sec. 3):
● The Department of Health (DOH) shall be
responsible for the following:
○ formulation and development of national
health policies, guidelines, standards and
manual of operations for health services
and programs;
○ issuances of rules and regulations, licenses
and accreditations; promulgation of
national health standards, goals, priorities
and indicators; development of special
health programs and projects and advocacy
for legislation on health policies and
programs.
● The primary function of the Department of
Health is the promotion, protection,
preservation or restoration of the health of the
people through the provision and delivery of
health services and through the regulation and
encouragement of providers of health goods and
services.
● THE DOH IS THE LEAD AGENCY FOR PHILIPPINE
HEALTH CARE.
Vision
Health for ALL Filipinos
Mission
To ensure accessibility and quality of health care to
improve quality of life of all Filipinos, especially the
poor
The Philippine Health System
The Department of Health (DOH)
---- is duty-bound to:
1. develop policies and programs for the health
sector
2. provide technical assistance to its partners
3. encourage performance of the partners in the
priority health programs
4. develop and enforce policies and standards
5. design programs for large segments of the
population
6. and provide specialized and tertiary level care.
Directions of the Philippine Health Sector
1. The Philippine Health Agenda 2016-2022
(DOH Administrative Order 2016-0038) -
“All for Health Towards Health For All”
2. The Philippine Development Plan 2017-2022
- “Matatag, maginhawa at panatag na
buhay”
3. NEDA AmBisyon Natin 2040 - “AmBisyon”
4. Sustainable Development Goals 2030
It’s more fun in the Philippines
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OVERVIEW OF HEALTH INFORMATICS
Health Information Technology
(Rouse, 2016)
- the area of IT involving the design,
development, creation, use and maintenance of
information system for the health care industry.
- automated and interoperable HIS are expected
to improve medical care, lower cost, increase
efficiency, reduce error, and improve px
satisfaction while also optimizing reimbursement
for ambulatory and in-px health care providers"
Kushniruk & Borycki, 2017)
- vows to provide innovation to health care
delivery and connection among users and
stakeholders in the e-health market.
- systems such as electronic health records,
decision support system and personal health
records are promising and becoming widely
deployed worldwide.
A. Health Care Software Systems:
1. Electronic Health Record (HER) / Electronic
Medical Record (EMR)
● fundamental components of health
information technology infrastructure.
○ Personal Health Record (PHR)
○ Health Information Exchange (HIE)
2. Picture Archiving and Communication
Systems (PACS)
3. Vendor Neutral Archives (VNA)
● Manage and store the patient’s medical
images
● Both integrate radiology into the main
hospital workflow
● Radiology, cardiology and neurology are
among the large scale producers of clinical
images.
● VNAs can be also be installed for the
purpose of merging stored imaging data
from various departments into
multi-facility health care system.
B. Health Information Ecosystem:
Healthcare Information and Management System
(HIMS) 2017
● as a composition of individuals, systems,
and process that share, exchange and
access all forms of health information,
including discrete, narrative and multimedia
C. Health Informatics in the Cloud:
Advantages of Cloud Technology
1. Integrated and Efficient Patient Care
2. Better Management of Data
Disadvantages of Cloud Technology
1. Potential Risk to Personal Information
2. Cloud Setup Seems Cumbersome
Health Informatics in the Philippines
Health Informatics:
● application of both technology and systems
in a healthcare setting
● Community Health Information Tracking
System (CHITS)
○ a Linux, Apache, MySQL, PHP-based system
released under the general public license
(GPL)
■ an electronic medical record (EMR)
developed through the collaboration
KEY ELEMENTS FOR EFFECTIVE ROOT CAUSE
ANALYSIS & PROBLEM-SOLVING
Visual Definition of Problem
● Gap between current condition, (what is), and
the desired performance level, (what must be,
should be or could be)
● This gap can exist in a process, product or
system
● A problem can only be considered to be valid if
● "what should be" is specified
Where do "gaps" arise?
● Customer complaint
● Nonconforming output of a process
● Out-of-control process
● Management systems not being followed
● Safety incidents
● Environmental "releases"
● Goals not being achieved
● Can be actual, potential or generated
Communication of Problems
CREI Problem Statement
A tool for communicating the gap:
● Concern: what is wrong; statement of
nonconformity
a
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● Requirement: what should be; documented
requirement or reference to
● Evidence: data demonstrating that something is
wrong; objective evidence observed that
supports statement of nonconformity
● Impact: how significant is the problem from a
performance and/or cost standpoint
Concern
● What is wrong?
● What is different than what should be?
● May be recognized as a symptom, (effect), or as
a failure condition, (failure mode)
● Define in terms of requirement, (language of
organization)
Requirement
● What should be
● Must be defined and valid
● Can be found in procedures, policies, drawings,
specifications, etc.
● #1 reason problems are not effectively solved is
that Requirement is not clearly known or defined
● Reference where Requirement can be found
● State as defined in Requirement document
Evidence
● Demonstrates requirement is not being fulfilled
● Data initially gathered associated with problem
● Objective evidence collected while auditing
process or system
● Must be verifiable
● Can be tangible, a statement of admission or
observed
Impact
● How big is the problem?
● How much does it cost?
● Is the customer affected?
● Is it affecting fulfillment of organizational goals?
● Refer to effect and severity ranking on FMEA for
performance impact
● Also consider cost impact
● In the case of auditing findings: typically,
auditors do not cite Impact as this could be
viewed as subjective
● Impact should be determined by auditee upon
their review of the audit finding
Utilizing CREI Format
● Incorporate these fields on problem solving and
nonconformance report formats to prompt
complete recording of information re: problems
● May require some investigation to identify
necessary information for completing CREI
statement, especially location and actual
statement of "Requirement"
● Critical success factor to effective problem
solving is consistent and complete
communication of problem condition
Problem Categories and Problem Solving
Approaches
Types of Problems
● Simple cause known; "Just do it" issues
● Complex, cause unknown; need to dig deeper
issues
● Sometimes the financial impact of a problem
dictates how it will be classified
"Just Do It" Issues
● Typically isolated, sporadic incidents
● Are easily fixed; apparent cause tends to be
known
● Often recognized during process planning and
reflected in PFMEA
● Addressed through troubleshooting (diagnosis
and remedy) and reaction plans on control
plans, (control of nonconformity)
● Can be fixed by process owner; addressed at
process level
● Occurrence should be monitored ongoing for
cost and impact
"Dig Deeper" Issues
● Sometimes referred to as Chronic
● Long-term and/or complex issues
● Cause is not readily apparent, unknown
● Require in-depth investigation to identify root
cause
● Addressed through root cause analysis
disciplined problem solving and improvement
process
● Source of problem typically unknown
● Cross-functional participation needed to solve
● Effective resolution requires both process and
system solution consideration
● Require management intervention via resource
commitment
● When available data re: problem is limited, may
be handled as "Just do it" based on impact
and/or risk
Steps in Disciplined Problem Solving
1. Establish Team
2. Operational Problem Definition
3. Containment & Interim Actions, (if needed)
4. Root Cause Analysis, (process & system)
5. Plan & Implement Solutions
6. Results of Solutions
7. Verification, (including independent)
8. Closure & Congratulate the Team
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Problem Type Considerations ● Impact portion of CREI statement facilitates
prioritization of problems for allocation of
Just Do It Dig Deeper
problem-solving resources
● Management is responsible for establishing the
● Reflects product or ● Unanticipated
priority
process controls conditions which
established when occur
● May also be The Secret to Solving Problems
planning the
anticipated issues ● The source of every problem is a process
process for which actual typically the gap is found in the output of the
● Management level of risk is now process
decision to "live determined to be
● The cause of every problem is one or more
with" such unacceptable
process factors not behaving as they should
conditions based ● Require
concentrated ● Understanding the relationship between
on acceptable level
investigation to process factors and process outputs is
of risk
understand source important to effective problem solving
● Should be routinely of problem and ● Data about the process and the problem is
evaluated for cost process factors required to gain enough understanding to
and impact leading to problem
effectively solve any problem
● Can only be condition to allow
appropriate ● The result of any problem solving effort is
eliminated by
solutions increased knowledge about processes and their
applying disciplined
outputs
problem solving to
understand true
Components of Process
root cause in order
to improve process

A Note about Fire-fighting!

● Fire-fighting is essentially un-prescribed actions
taken on a process without understanding the
relation of causal factors and process output
● Fire-fighting is dangerous as these actions tend
not to be specifically focused to a particular
cause
● The resulting impact of firefighting is typically What are the Process Factors?
not known ahead of time Processes are mainly influenced by:
● Therefore, chaos is introduced into the process ● Man
● A very high-risk approach to problem-solving! ● Material
● Machine
Problem Type Considerations ● Methods
● Mother Nature, (environment)

Other factors which influence processes include:

● Measurement
● Management System, (policies including SOPs,
targets, operational decisions)
● Money
● Other?

Process View
Prioritize Problems
● Most organizations should only be actively
working on 3-5 disciplined problem solving
efforts, (Dig Deeper issues), at a time to
balance the use of resources and get the most
effective solutions; (no one person should be
working on more than 2 Dig Deeper teams at
any given time) Main Functions of Problem Solving

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● Define Gap between "what is" and "what should ● Identify what data to collect that would assist in
be" answering the question
● Identify process of origin from which gap is ● Determine where that data can be obtained
originating ● Decide how to go about collecting the data;
● Study the process of origin to determine which what tools/methods to apply
process factor(s) are causing the gap ● Go collect the data
● Analyze the relationship between process causal ● Review and analyze the data to draw a
factors and system factors to identify root cause conclusion re: questions being posed
● This is an important step in Root Cause Analysis
Getting to the Process of Origin as the results of this investigation provide a
● Where was the problem found? context for the root cause investigation
● Where is the first process the problem condition ● By conducting Is/Is Not Analysis, it is also
could occur? possible to détermine if fürther investigation can
● Go to these and any processes in between to take place at this time
collect data recognizing where the problem is
actually first observed; this is the process of Components of Problem's Operational
origin! Definition
● Use a process flow diagram to make this ● Basis for root cause investigation
investigation visual ● More detailed version of CREl statement based
on what was learned from Is/ls Not
Is/Is Not Analysis ● Indicate process from which problem
● Also known as Stratification Analysis originated/generated
● Provides further detail about the problem so a ● Indicate direction of problem-related to
complete operational definition of the problem requirement
can be formulated. ● Define extent of problem
● Used at this stage as well as in applying ● Possibly isolates problem to a certain timeframe
interim/containment actions and ● Include refined information re: impact
implementing/verifying permanent actions. ● Problem statement must be clear, concise and
● "Splitting the dictionary" or "20 questions to the understandable by anyone
answer" demonstrates this idea of problem
convergence ROOT CAUSE

Use Data to determine A process factor which directly defines the reason for
● What is the problem? - define the problem the problem when it is present and is having an
condition such that anyone could recognize it; influence on the process and its output.
basis for data collection about the problem
● Where is the problem occurring? - which 4 Levels of Root Cause
processes, customers; also, where on the output
is the problem condition observed?
● Who knows about the problem? - who initially
identified the problem? Who else has seen this
problem? Who is involved in the process steps
reflected in the process flow?
● When did the problem begin? - timeline
associated with when the problem was seen; can
be applied even for ongoing problems
● How big is the problem? - how much output is
affected? Dig! How Deep?
● Narrows the problem focus to isolate the ● Management decides on depth of root cause
problem to its process of origin investigation through the establishment of
● Data is collected to demonstrate answers to SMART goals for each problem solving effort.
these questions
Problem Solving Goals
Applying Is/Is Not Analysis ● Define problem's boundaries/depth of solutions
● Clarify aspect - what question needs to be ● Identify right people to solve problem
answered to obtain a better understanding of ● Establish measures of end results
the problem ● Develop plan of how to accomplish the goal

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● Tie problem solving goals to organizational ● Were controls defined to recognize and contain
objectives/targets the problem?
● Provided to team by Management ● At which process are the planned controls
applied?
Effective Problem Solving is based on ● Were the planned controls in place?
SMART Goals ● Were the planned controls working?
● Specific ● What is the capability of these controls?
● Measurable ● Assists in identifying appropriate interim actions
● Agreed upon by team as attainable as well as identifying the defect/detection root
● Relevant to organization and results-oriented cause
● Timing defined
Results of Control Barrier Analysis
Root Cause Analysis ● May recognize missing controls or controls not
● Systematic investigation of a process to identify working as planned
the root cause of the gap, and take corrective ● Interim actions represent solutions to addressing
action to eliminate the gap and keep it from these concerns but should not be accepted as
occurring again in the future the permanent solution
● A structured investigation that aims to identify ● When the results of this analysis uncover
the true cause of a problem, and the actions additional problems, refer these to the team
necessary to eliminate it. champion for direction on addressing
● Team's main focus at this point is to implement
Process Cause vs. System Cause some type of control to protect downstream
processes from continuing to experience the
Process Cause System Cause
problem
● Solutions based on this level of "root cause
● What factor of the ● Addresses how the
investigation" mainly are reactive in nature;
process of origin is management
they only improve our ability to detect the
triggering the system allowed the
problem condition but don't typically do anything
undesirable output process to become
about addressing the root cause!
● What other out of control
processes and their ● Relates process
Direct Process Cause
factors are causing factor causes to
● Relates one or more factors of the affected
the trigger? "weaknesses" in
process, (process of origin), not "behaving"
● Relates product management
required to obtain the desired output result at
output, systems
that process
(symptom), to policies/practices
● Use Cause & Effect diagram, (fishbone
process
technique)
parameters,
● Direct process causes, (trigger causes), are the
(causes)
starting point for identifying root cause
● Some action may be required to address the
Root Cause Analysis Levels direct process/trigger cause but actions should
not be taken until actual root cause is known

Cause & Effect Diagram

Control Barrier Analysis (Defect/Detection Root
Cause)
● How did the problem escape the process and/or
organization?
● Was the problem anticipated in advance?
● Apply to problem's process of origin
● Gap is head of fish
● Major cause categories
- 5M's
● Potential causes brainstormed are process
factors existing at the problem's process of
origin
● Define potential causes specifically
● When confirmed, these will be known as direct
process/trigger causes

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Fishbone Diagram
Fishbone Process
● Involve personnel from process of origin in
brainstorming of potential causes at the process
of origin triggering the problem
● Develop a sketch/list of the process factors,
(man, material, machines, methods, mother
nature), related to the process of origin
● After brainstorming, review each identified cause
to establish:
○ If the cause is actually a factor at the
process of origin
○ If the cause makes sense based on the
operational definition of the problem
● Prioritize remaining causes as to their possible
contribution to the problem condition
● Develop hypothesis test to evaluate each
potential cause at the process of origin
Problem Understanding Tools
(especially useful in identifying system causes)
● Task Analysis - reviews process in detail; helpful
for operator dependent process
● Change Analysis - identifies differences;
extension of Is/Is Not analysis; expands on
application of timeline
● Both these tools must be applied with a location
context, (process of origin)
Actual Root Cause
● Explains why trigger cause/condition exists at
the process of origin of the problem
● Typically found in previous "planning" processes
● Many problems have multiple causes
● Usually only one over-riding cause that when
addressed, can significantly reduce the problems
impact on the organization
● Very complex problems may have interacting
causes but these are typically viewed as isolated
problems that only repeat infrequently, (often
managed as Just Do It), until resources allow
necessary time to discover interaction through
data collection, analysis and experimentation
5 Why Analysis
● Ask "Why does this happen?" for each identified
process cause from Cause & Effect diagram
● Differentiates between process, (direct) cause
and underlying root cause Each level of causes
identified in 5 Why analysis must also be
confirmed via testing in order to verify root
cause
● Deeper levels of 5 Why analysis which get into
● Planning processes will require interview-type
data collection
Test Potential Root Causes
● Validating cause "quesses" by collecting and
analyzing data
● Test under controlled conditions
● Turn the problem on and off by
manipulating the suspected cause
Hypothesis Testing
● Design hypothesis and select methods for
testing hypothesis - state how potential cause
could result in described problem; decide what
data to collect that would prove potential cause;
establish acceptable risk of decision outcome;
determine sample size; develop action plan for
study
● Prepare to test hypothesis - organize and
prepare materials required to conduct study;
collect data during study
● Analyze results of test - analyze data using
appropriate statistical tools, (t, F, Chi-squared
tests)
● Interpret results - conclusions from study;
does data establish potential cause as reason for
problem?
Root Cause Analysis Plan
● Identify causes to be investigated
● What data supports each cause?
● Can cause be introduced and removed to
confirm presence/absence of problem?
● What tests will be performed to confirm root
cause?
● What is the statistical confidence of these tests?
(i.e. how much data is needed?)
● Results of tests recorded and analyzed with
conclusions drawn
System Causes
● What in the system allowed this problem/cause
to occur
● Identifies why the process root causes occurred
based on current management policies/practices
● Often not readily measurable
● Data obtained through interview
● By identifying system causes, systemic
improvement can be made in order to prevent
recurrence of problem in other similar processes
● Typically addressed once process root causes of
problem are known and confirmed
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Problem Solutions
● There are always at least 3 possible solutions
related to each level of cause
● at least 12 possible solutions could be identified
for a problem investigation if all levels of cause
are investigated!
● Management provides solution selection criteria
as basis for evaluating possible solutions
3 Possible Solutions
● Eliminate root cause: preventive control; often
referred to as error-proofing; eliminates causal
factor leading to problem condition
● Control root cause: process detective control
implement actions to monitor cause condition so
action can be taken on process factor before
problem occurs
● "Do nothing": reactive control; continue
monitoring for problem condition; defect
detection solution; may be required when root
cause can't be eliminated/controlled
economically or technically; may include
accepting interim action as permanent solution
Solution Selection
● Allow brainstorming of possible solutions at all
levels of confirmed causes and the 3 possible
categories of solutions
● Then apply solution selection criteria provided by
management to evaluate each possible solution
as well as refine the brainstormed ideas
● Have data available re: actual costs associated
with problem, (initial impact, revised impact
based on data collection/analysis, anticipated
future impact if no action is taken)
Implementing Solutions
● Actions to eliminate and control causes require
change
● Change management tools should be applied
when implementing solutions
Change Management Tools
● FMEA
● Risk assessment
● Resource planning
● Contingency planning
● Training
● Evaluation
● Verification
Other Opportunities
● Identified typically while collecting data for Is/ls
Not Analysis, Root Cause
investigation/confirmation, solution evaluation
● Record these other problems/opportunities
● Share these problems/opportunities with team
champion to get direction on how to address:
(change scope of current problem solving effort
to include; management assigns another team
to address)
● Don't allow these other opportunities to distract
from the focus of the problem solving effort
● These Other Opportunities become the "Bonus"
of an effective problem solving effort
FISHBONE DIAGRAM
Fishbone Diagram
● Identifies and organizes the potential causes of a
business problem.
● Uses an easy and understandable format.
● Used to identify the sources of process variation.
● It is also called Ishikawa Diagram and Cause and
Effect
● Identifies the causes of an undesirable effect of
a problem.
● It is also possible to identify the hierarchy of
causes including the possible root causes.
● Brings attention to the primary factors affecting
the quality of a product or service.
● These factors need to be optimized in order to
reduce the amount of process variation.
● The outcome can provide initial information to
later problem-solving tools.
● Root Causes are Normally:
○ Those at the ends of chains of causes.
○ They do not have any sub-causes.
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● Often used during brainstorming sessions.
● Everyone gains insight into the cause and effect
● This makes the solution easier to find later
● Helps to create ideas about the possible causes
of a problem before it happens.
● An effective cause prevention tool.
● Helps to identify the potential factors causing an
effect to prevent future problems.
● Can also be used in product design and to plan
new processes.
● Potential causes are sometimes called the
process input variables.
● They are normally grouped into categories for
easier sharing and reference.
● These are often called the 6 Ms.
Man: anyone involved with the process and
contributes to the effect.
Methods: how the process is performed and the
specific requirements for doing it, such as:
● Policies
● Procedures
● Rules
● Common practices
Machines: including the equipment and tools
required to do the process.
Materials: The material needed to produce the
product or provide the service, including:
● Raw materials
● Parts
● Papers
● Packing
● Consumables
Typical Fishbone Diagrams for Manufacturing and
Non-manufacturing Processes:
How to Construct a Fishbone Diagram:
● Clearly define the effect of the problem.
● Write it down at the center right of a large piece
of paper.
● Determine the major categories of causes.
● Write them on the branches of the diagram.
● Use brainstorming to log all possible causes
under the appropriate branches.
● Use 5 Whys to search for root causes then add
them to the diagram.
● Take time to ensure the appropriateness of the
recorded information.
● Update the chart as new causes become
apparent.
● Mark or assign numbers near to the key causes
to show their relative priority.
● Collect data and investigate to verify the key
causes are actual.
● Plan and implement actions to address the key
causes.
Ways of Finding More Causes:
● Keep asking questions to encourage everyone to
participate.
● Involve other people, especially those who have
experience in the process.
● Leave the chart on the wall for few days and
encourage passers-by to contribute.
● Take a break or do something to take the team's
mind off the current thoughts.
Further Information:
● Different names may be used for the same
category.
○ Procedures could be used instead of
Methods.
○ Equipment could be used instead of
Machines.
● You may even create your own branches that
suit your needs.
● affinity diagram: could be used to create the
branches of the diagram from the titles of the
affinity sets.
● Don't overload categories.
○ Establish another category if needed.
● You could also create sub categories under the
main categories
● For example, under Man there might be:
○ Poor Communication
○ Absenteeism
○ Lack of Training
● You should, however, avoid writing real names of
persons.
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● Beware of adding causes which are actually
solutions.
● A Cause and Effect Matrix could be used to
prioritize the causes of the problem.
● Prioritizing and selecting the key causes will
minimizes the need for more statistical
evaluation of inputs that are unlikely to have an
impact on the output.
information, or when put together with other
information would directly and certainly identify
an individual
WHAT IS SENSITIVE PERSONAL INFORMATION?
PERSONAL INFORMATION THAT IS ABOUT AN
INDIVIDUAL’s:

DATA PRIVACY ACT of 2012

● Republic Act 10173
● It is the policy of the State to PROTECT THE
FUNDAMENTAL HUMAN RIGHT OF PRIVACY,
of communication while ensuring the free flow of
information to promote innovation and growth.
● The state recognizes the vital role of information PRIVILEGED INFORMATION
and communications technology in ● Any and all forms of data which under the Rules
nation-building and its inherent obligation to of Court and other pertinent laws constitute
ensure that personal information in information privileged communication.
and communications systems in the government
and in the private sector are secured and PRIVILEGED COMMUNICATION
protected. ● is interaction between two parties which the law
recognizes as PRIVATE, PROTECTED relationship.
IMPLEMENTING RULES AND REGULATIONS of ● Whatever is communicated between these
Data Privacy Act by the National Privacy parties shall remain CONFIDENTIAL and the law
Commission CANNOT FORCE DISCLOSURE of these
communications.
“Pursuant to the mandate of the National Privacy ● Ex: A client confessing medical conditions to a
Commission to ADMINISTER and IMPLEMENT the psychiatrist, etc.
provisions of DATA PRIVACY ACT of 2012, and to
monitor and ensure compliance of the country with Data subject
international standards set for data protection, the ● refers to an INDIVIDUAL whose personal
following rules and regulations are hereby information is processed.
promulgated to effectively implement the provisions ● Ex: Using you name, age and address in a
of the Act.” survey.

RULES
● further enforce the Data Privacy Act and adopt a
generally accepted international principles and
standards for personal data protection.
RULE 1: PRELIMINARY PROVISIONS
CONSENT
● of the data subject refers to any freely given,
specific, informed indication of will, whereby the
data subject agrees to the collection and
processing of personal information about and/or
relating to him or her.
● shall be evidenced by written, electronic, or
recorded means.
● It may also be given on behalf of the data
subject by an agent specifically authorized by
the data subject to do so.

PERSONAL INFORMATION
● Any information whether recorded in a material
form or not, from which the identity of an
individual is apparent or can be reasonably and
directly ascertained by the entity holding the

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More Definitions in Rule I
RULE II: Scope of Application
The Data Privacy Act and these rules apply to the
processing of personal data by any natural and
juridical person IN THE GOVERNMENT OR PRIVATE
SECTOR. These rules apply to an act done or practice
engaged IN AND OUTSIDE THE PHILIPPINES IF:
SPECIAL CASES (PUBLIC OFFICERS and EMPLOYEES)
● Information about any individual who is or was
an officer or employee of a government
institution that relates to the position or
functions of the individual, including:
SPECIAL CASES (GOVERNMENT CONTRACTORS)
● Information about an individual who is or was
performing service under contract for a
government institution that relates to the
services performed, including the terms of the
contract, and the name of the individual given in
the course of the performance of those services;
SPECIAL CASES (DISCRETIONARY BENEFITS)
● Information relating to any discretionary
benefit of a financial nature such as the
granting of a license or permit given by the
government to an individual, including the name
of the individual and the exact nature of the
benefit;
SPECIAL CASES (JOURNALISTIC, ARTISTIC,
LITERARY and RESEARCH)
● Personal information processed for journalistic,
artistic, literary or research purposes;
SPECIAL CASES (TO CARRY OUT FUNCTIONS OF
PUBLIC AUTHORITY)
● Information necessary in order to carry out
the functions of public authority which
includes the processing of personal data for the
performance by the independent, central
monetary authority and law enforcement and
regulatory agencies of their constitutionally and
statutorily mandated functions.
SPECIAL CASES (FOR COMPLIANCE WITH RA 9510
and 9160)
● Information necessary for banks and other
financial institutions under the jurisdiction of the
independent, central monetary authority or
Bangko Sentral ng Pilipinas to comply with
Republic Act No. 9510, and Republic Act No.
9160, as amended, otherwise known as the
Anti-Money Laundering Act and other applicable
laws
SPECIAL CASES (RESIDENTS OF FOREIGN
JURISDICTIONS)
● Personal information originally collected from
residents of foreign jurisdictions in
accordance with the laws of those foreign
jurisdictions, including any applicable data
privacy laws, which is being processed in the
Philippines.
PROTECTION AFFORDED TO JOURNALISTS AND
THEIR SOURCES
● NOTHING IN THIS ACT shall be construed as to
have amended or repealed the provisions of
Republic Act No. 53, which affords the
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publishers, editors or duly accredited reporters
of any newspaper, magazine or periodical of
general circulation protection from being
compelled to reveal the source of any news
report or information appearing in said
publication which was related in any confidence
to such publisher, editor, or reporter.
information controller, his or her RIGHTS as a
data subject, and HOW THESE CAN BE
EXERCISED.
● Any information and communication relating to
the processing of personal data should be EASY
TO ACCESS AND UNDERSTAND, using CLEAR
and PLAIN LANGUAGE.

RULE III: National Privacy Commission LEGITIMATE PURPOSE

MANDATE:
● The National Privacy Commission is an
independent body mandated to administer and
implement the Act, and to monitor and ensure
the compliance of the country with international
standards set for personal data protection.
SECRECY OF BANK DEPOSITS, FOREIGN CURRENCY
DEPOSITS, CREDIT INFORMATION SYSTEM
● NOTHING IN THIS ACT shall be construed as to
have amended or repealed Republic Act No.
1405, otherwise known as the Secrecy of Bank
Deposits Act; Republic Act No. 6426, otherwise
known as the Foreign Currency Deposit Act; and
Republic Act No. 9510, otherwise known as the
Credit Information System Act (CISA);
● “The processing of information shall be
COMPATIBLE WITH DECLARED AND SPECIFIED
PURPOSE which must NOT be contrary to law,
morals, or public policy.”
PROPORTIONALITY
● The processing of information shall be
ADEQUATE, RELEVANT, SUITABLE, NECESSARY,
and NOT EXCESSIVE in relation to a declared
and specified purpose. Personal data shall be
processed only if the purpose of the processing
could NOT reasonably be fulfilled by other
means.
COLLECTION, PROCESSING, and RETENTION
Processing of personal data MUST ADHERE to these
principles:

FUNCTIONS of NPC
● RULE MAKING
● ADVISORY
● PUBLIC EDUCATION
● COMPLIANCE MONITORING
● ENFORCEMENT
● Other functions

CONFIDENTIALITY OF PERSONAL DATA

● Members, employees, and consultants of NPC
shall ensure at all times the confidentiality of
any personal data that come to their knowledge
and possession: Provided, that such duty of
confidentiality shall remain even AFTER THEIR
TERM, employment or contract has ended.

RULE IV: Data Privacy Principles

GENERAL DATA PRIVACY PRINCIPLES
● Processing of personal data shall be allowed
SUBJECT TO COMPLIANCE with the requirements
of the Data Privacy Act and other laws allowing
information disclosure to public and adherence
to the principles of TRANSPARENCY,
LEGITIMATE, PURPOSE and
PROPORTIONALITY”

TRANSPARENCY
● Data subject must be aware of the NATURE,
PURPOSE, and EXTENT of the processing of his
or her personal data, including the RISKS and
safeguards involved, the IDENTITY of personal

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DATA SHARING PRINCIPLES
Further processing of personal data collected from a
party other than the Data Subject shall be allowed
under any of the following conditions:
Data sharing
● shall be allowed when it is expressly authorized
by law, with adequate safeguards for data
privacy and security, and processing adheres to
principle of transparency, legitimate purpose and
proportionality.
Remember: DATA SHARING AGREEMENT!
● SUBJECT TO REVIEW BY NATIONAL PRIVACY
COMMISSION
● ESTABLISH ADEQUATE SAFEGUARDS
● UPHOLD RIGHTS OF DATA SUBJECTS
Rights of the data subject shall be upheld without
compromising research integrity!
Data collected from parties other than the data
subject for the purpose of RESEARCH shall be
allowed when the personal data is publicly available
or has the consent of the data subject for the
purpose of RESEARCH. And, with adequate
safeguards, and that NO DECISION directly affecting
the data subject shall be made on the basis of the
data collected or processed
PRIVACY
● The right to be let alone - the most
comprehensive of rights and the right most
valued by civilized men
Data Privacy Act (DPA)
● A law protecting INDIVIDUAL PERSONAL DATA
● It is the policy of the State to protect the
fundamental human right of privacy of
communication while ensuring free flow of
information to promote innovation and growth.
Defining the terms
PERSONAL INFORMATION
● Any information from which the identity of an
individual is apparent
● Any information that can be put together with
other information to reasonably and directly
identify an individual
● Includes sensitive personal information such as
your health, education, genetic or sexual life
● Includes information that is classified or
privileged
Processing
● Any operation or set of operation performed
upon personal information.
To whom this law applies
● DATA SUBJECT
○ whose personal information is processed
● PERSONAL INFORMATION CONTROLLER
○ person or organization who controls the
processing and use of personal information
● PERSONAL INFORMATION PROCESSOR
○ may outsource the processing of personal
data pertaining to a data subject
Responsibilities of the PICs and PIPs
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GENERAL DATA PRIVACY PRINCIPLES Availability
Transparency ● Due to loss, accidental, or unlawful destruction
● The data subject must be aware of the nature of personal information
purpose, and extent the processing of his or
her personal data. Rights of the Data Subject
● PRIVACY NOTICE 1. Right to Information
○ tells you what happens to your personal 2. Right to Object
data. 3. Right to Access
○ who is collecting your information 4. Right to Correct
○ what it is going to be used for 5. Right to Erase
○ whether it will be shared to other 6. Right to Damages
organization 7. Right to File a Complaint

Legitimate purpose Penalties

● The processing of information shall be
compatible with a declared and specified
purpose.
● Section 12 & 13 Criteria for Lawful Processing
● other purposes:
○ marketing
○ medical mission
○ profiling
○ training and compliance to requirement of
board exams
○ case presentation
○ research for public benefit
○ and others

Proportionality
● The processing of information shall be
adequate, relevant, suitable, necessary, and
not excessive.

IMPLEMENTATION OF SECURITY MEASURES

Organizational Security
● Data Protection Officer
● Privacy Impact Assessment
● Training and Capacity building

Technical Security

Physical Security
● Design of office space and work stations,
including the physical arrangement of furniture
and equipment, shall provide privacy to anyone
processing personal data, taking into
consideration the environment and accessibility
to the public

TYPES OF BREACHES
Confidentiality Breach
● Due to the unauthorized disclosure of or access
to personal data

Integrity
● Due to alteration of personal data

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