Está en la página 1de 6

Making the Case for Quality

December 2015

Using Control Charts in a


Healthcare Setting
by Jack Boepple
At a Glance . . .
This teaching case study
features characters,
hospitals, and healthcare
data that are all fictional.
Upon use of the case
study in classrooms or
organizations, readers
should be able to create
a control chart and
interpret its results, and
identify situations that
would be appropriate for
control chart analysis.
The case is best suited
for MBA operations
courses and modules,
particularly those focused
on operations/process
improvement. It also could
be used in a hospital
setting at a facility that has
embraced a continuous
improvement philosophy.

After spending 10 years on the road as a healthcare operations improvement consultant, Isabella Izzy
Cvengros decided it was time to settle down. Although Cvengros loved what she was doing, she had
recently become engaged and wanted to spend more time with her future husband. However, with family members spread throughout the country, there was really no home to go back to.
As a consultant, Cvengros had been assigned to a wide variety of healthcare projects over the years,
learning a great deal. She also enjoyed seeing so many different parts of the United States, with a particular fondness for New Hampshire, so she and her fianc focused their job search there.
On October 10, 2014, Cvengros found herself with a good problem. She had just completed a series
of interviews with two Nashua, NH, hospitals: Farrell Memorial Hospital and Penner Mobley Health
Services, and both had gone very well. She interviewed for the same job at both facilitiesdirector of
operations improvementand leadership from both facilities indicated she was proceeding to the final
round of interviews, which entailed meeting each hospitals executive team.
As a certified Lean Six Sigma Black Belt, Cvengros was thrilled to hear both hospitals progressive
views on continuous improvement. While she saw examples of many quality tools and analyses being
performed at each hospital, she did not notice any control charts being used.
Although control charts are typically associated with manufacturing processes, Cvengros knew they
could be applied to any industrys processes, including hospitals.
Because she had employed control charts with great success in several of her assignments, she incorporated this experience as part of her interview responses. Both hospitals were intrigued and asked
if she could provide an example during her next round of interviews. Cvengros agreed, but to make
the analysis more meaningful, she asked each hospital to provide her with data so the example control chart analysis would be more meaningful and relevant to them. Since one of the key discussion
points during her interviews at both facilities revolved around reducing the patients length of stay,
Cvengros asked for data on their estimated date of discharge (EDD) by week from January through
September 2014.

About Farrell Memorial Hospital


Farrell Memorial Hospital is a 400-bed general medical and surgical hospital located in Nashua, NH.
The hospital, which is part of a larger statewide healthcare system, has won numerous awards over
the years, including for patient safety, performance in its rehabilitation patient care unit, and critical
care excellence.

ASQ

www.asq.org

Page 1 of 6

About Penner Mobley Health Services


Penner Mobley Health Services is a 500bed general medical and surgical hospital
in Nashua. Part of a regional health system,
Penner Mobley has also received numerous awards, including being named a top-50
hospital in the country for the past six years,
recognized for its high-quality and innovative
nursing care, and recognized as a performance
improvement leader.

Assessing Hospital Performance


The Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS)
is a national patient satisfaction survey that
asks patients about their experiences during a
recent hospital stay.1 The responses are broken
down into the following categories:





Survey of patients experiences


Timely and effective care
Readmission, complications, and deaths
Use of medical imaging
Medicare payment
Number of Medicare patients

Within some categories are sub-categories.


For example, in the Timely and effective
care category, there were 10 sub-categories,
including heart attack care, surgical care, and
pregnancy and delivery care.
The results are maintained by Centers for
Medicare and Medicaid Services, CMS.gov,
(Medicare) and anyone can compare one
hospital vs. another on Medicares Hospital
Compare website2. Knowing this, Cvengros
ran a report of patients experiences category
results for both Farrell Memorial and Penner
Mobley as compared to the state and national
averages (see Table 1).
Both hospitals ranked below the state and
national averages in many of the categories.
Cvengros was surprised by the ranking of
Penner Mobley Health Services as it is a
Magnet-recognized organization. Recognized
by the American Nurses Credentialing Center,
a Magnet designation recognizes hospitals
with high-quality, innovative nursing and
best practices for patient care, particularly
in the areas of nurse communication (Q1),

ASQ

Table 1 HCAHPS Survey of Patients Experiences, October 2014


#

Question

Farrell
Memorial

Penner
Mobley

State
Average

National
Average

Patients who reported


that their nurses Always
communicated well

73%

77%

79%

79%

Patients who reported that


their doctors Always
communicated well

76%

81%

81%

82%

Patients who reported that


they Always received help
as soon as they wanted

62%

63%

70%

68%

Patients who reported that


their pain was Always
well controlled

66%

68%

72%

71%

Patients who reported that


staff Always explained
about medicines before
giving it to them

61%

62%

67%

64%

Patients who reported that


their room and bathroom
were Always clean

65%

66%

74%

73%

Patients who reported that


the area around their room
was Always quiet at night

52%

63%

64%

61%

Patients who reported Yes,


they were given information
about what to do during
their recovery at home

84%

87%

87%

85%

Patients who gave their hospital


a rating of 9 or 10 on a scale
of 0 (lowest) to 10 (highest)

64%

73%

75%

71%

68%

77%

76%

71%

10 Patients who reported


Yes, they would definitely
recommend the hospital

availability of help (Q3), and receipt of discharge information (Q8). Cvengros


found it interesting their performance was rated lower than the state and national
averages on nursing communication (Q1), the availability of help (Q3), pain control (Q4), and explanation for medications (Q5).

Estimated Date of Discharge


One of the cost reduction approaches employed by hospitals is to reduce the
patients length of stay (LoS). One of the strategies embedded within this
approach is to actively plan the patients discharge. Like anything else, developing a plan and setting a target date for completion of a task increases the
likelihood the task will be completed on time (vs. no planning and/or coordination of resources). While task planning is a project management fundamental
(similar to work breakdown structure), it is still a relatively new concept in the
healthcare field.
In hospitals, the project teams are composed of the patients physician, nurses,
and ancillary professionals (such as pharmacists, physical therapy, occupational
therapy, and social workers). The composition of the team was dependent upon
the specific patients condition. So, there could literally be as many project

www.asq.org

Page 2 of 6

teams as there are patients. Depending upon the hospital, these project
teams might be called different names, such as a multidisciplinary team or
an inter-disciplinary team.
Whereas the review/update of a typical project plan might be done on a
weekly basis, the tasks (i.e., patients) must be reviewed/updated on a
daily basis. And with a large number of patients and various demands upon
each caregiver specialty, coordinating a hospital project team can be a
daunting task. Many hospitals have tackled this task by creating multidisciplinary rounds.
According to the Institute for Healthcare Improvement: With multidisciplinary rounds, disciplines come together, informed by their clinical
expertise, to coordinate patient care, determine care priorities, establish
daily goals, and plan for potential transfer or discharge. This patientcentered model of care has proven to be a valuable tool in improving the
quality, safety, and patient experience of care.3
One barometer to assess the effectiveness of multidisciplinary rounds was
to measure EDD, which is one of the primary outcomes for each patient
discussed during multidisciplinary rounds. Setting an EDD prompted active
discussion on the barriers preventing a patients release. A natural byproduct of these discussions is to streamline the transition of care for patients
(i.e., it helped reduce/minimize unnecessary clinical variation in treatment).
It also fosters a team, rather than an individual, approach to patient care.
Mathematically:
EDD
=
Accuracy

Number of Estimated Discharges Actually Discharged


Number of Potential Discharges

And:
Number of Estimated Discharges Actually Discharged
Number of
Potential
= + Number of Estimated Discharges Actually Not Discharged
Discharges
+ Number of Discharges Not Estimated

Although there is no ideal goal for EDD accuracy, higher is better than
lower. A lower rate and/or a stuck rate, is symptomatic of a problem.
It requires analyses to determine the cause of the problem. In general, a
low rate is indicative that (a) the staff is not communicating effectively, or
(b)not taking the estimation of discharge dates seriously.

Control Charts
All processes have variation. The challenge is to determine whether or not
the variation is common cause (or random or noise) or special cause
(or nonrandom variation).
According to iSixSigma, an online clearinghouse for process improvement,
common cause variation is fluctuation caused by unknown factors resulting in a steady, but random, distribution of output around the average of
the data. Special cause variation is the inverse: variation caused by factors
that result in a nonrandom distribution of output. It is also referred to as
exceptional or assignable variation.6 Determining the cause of special
cause variation typically requires further analysis/investigation.

ASQ

www.asq.org

As noted by Jackie Birmingham, vice president


of regulatory monitoring and clinical leadership at Curaspan Health Group,4 correctly
estimating the date of discharge has several
positive benefits/effects:
1. Improves care transition. According to Health
Affairs (a journal of health policy thought and
research): The term care transition describes
a continuous process in which a patients care
shifts from being provided in one setting of care
to another, such as from a hospital to a patients
home or to a skilled nursing facility (SNF) and
sometimes back to the hospital. Poorly managed
transitions can diminish health and increase
costs.5 Estimating the date of discharge helped
improve the communication/coordination with
the patients post-hospital destination.
2. Improves expectations setting with patients
and their families. Part of setting an estimated
discharge date is communicating it with
the patients and their families. While the
estimate is just thata targetthe net effect
is to improve the communications between
all parties. Most people cope better with the
known (vs. the unknown). By communicating
the EDD to the patients and their families,
some of the mystery is removed, and it
brings them into the conversation.
3. Enables reduced unnecessary clinical
variation in treatment. Standardized care
plans for specific-case types (e.g., sepsis) lists a
sequence of services needed by patients, based
on an anticipated LoS. Criteria sets are used to
monitor patients clinical progress to determine
whether a continued stay is medically
necessary. Embedded in both standardized care
plans and criteria sets is a timing component,
and the EDD helps quantify it.
4. Enables more efficient hospital operations.
Capacity management, bed management, and
patient throughput are all dependent on EDD.
5. Prepares for the future. Given the evolution
of healthcare in recent yearswith increased
responsibilities for utilization reviewers, use of
recovery audit contractors, and focus on denial
managementjustifying and documenting LoS
has grown ever-more important. As such, EDD
seems destined to be measured and monitored
as some reimbursement metric.

Page 3 of 6

Figure 1: Example of a Control Chart

NP Chart of 3T
UCL = 25.90

25

20
Sample Count

For example, think of


weighing yourself every
morning. One day a six-foot
man might weigh 201.2
pounds. The next day he
is 200.4 pounds. The following day he is 200.8
pounds. Over time, he is
probably hovering around
201 pounds, +/- two pounds.
His weight is demonstrating normal (common cause)
variation. Come Christmas
holidays/vacation, however,
his weight might balloon
to 205 pounds. In this case,
the special cause variation is rather apparent: He
consumed far more calories
than he expended during
the holiday. Unfortunately,
identifying the special cause
is rarely as straightforward.

15

NP = 14.56

10

5
LCL = 3.21
0
1

13

17

21
25
Sample

29

33

37

41

45

Control charts show what


type of variation is occurring
Figure 2: Control Chart Decision Tree
in a process. Synonymous
with statistical process
Are the data measured
Is each data point a
Are the data
Yes
Yes
Yes
control, control charts are a
on a continuous scale?
natural subgroup?
normally
Chart of individuals
(e.g., time, weight,
(such as one batch)
distributed?
graphical view of a process.
temperature)
or
No
Special tests are conducted
Moving average
Variable Data
Are
data
gathered
moving range chart
against the data to deterinfrequently?
_
mine (a) the normal limits/
No
No
X_ and R chart or
variation of the process and
X and s chart
(b) whether or not these
The data are counted
limits have been violated.7
(e.g., defective items
Yes
Are defective
Can sample Yes p chart
or complaints)
Control charts can also be
items counted?
size vary?
Attribute Data
considered a run chart on
No
No
np chart
steroids. Run charts disThe number of
play observed data in a time
defects are counted
Can sample Yes u chart
8
Source:
Nancy
R.
Tagues
sequence. Control charts
(and
an
item
can
size vary?
The Quality Toolbox, Second Edition,
take the simple run chart and
have many defects)
ASQ Quality Press, 2005.
No
apply some statistical rigor
c chart
to them. Basically, the mean
(average) is calculated and
drawn on a graph. The individual data points then are plotted on
When introduced in the 1920s, control charts were drawn on
the same graph. Then, the control limits are also drawn as +/graph paper. More recently, specialized computer programs
three standard deviations from themean.
(such as Minitab) can create these automatically.
Figure 1 is an example control chart (with no rules violations). The middle (green) line is the mean. The upper and
lower (red) lines are the upper control limit (UCL) and lower
control limit (LCL).

ASQ

The type of control chart used depends upon the type of data
variable (continuous) or discrete (attribute). Figure 2 provides
a decision tree on how to select the appropriate control chart.
Figure 1, for example, is an NP chart.

www.asq.org

Page 4 of 6

The types of tests that


can be run to determine
whether a process is out of
control varies by data type.
Continuous data has more
tests, but both attribute and
continuous data have the
same core four tests:

The first test is the one


typically associated with
control charts (see Figure3
for an example)a point
outside the control limits.

ASQ

NP Chart of 4s
14

12
1

10
Sample Count

1. 1 point > 3 standard


deviations from
centerline
2. 9 points in a row on
same side of center line
3. 6 points in a row, all
decreasing or increasing
4. 14 points in a row,
alternating up and down

Figure 3: Example of a NP Control Chart With Test No. 1 Violated

UCL = 9.35

8
6
4

NP = 3.64

2
0

LCL = 0
1

13

17

www.asq.org

21
25
Sample

29

33

37

41

45

Page 5 of 6

The number of points associated with each test above is essentially an industry standard, although software programs (such
as Minitab) allow you to configure/modify those values to suit
your specific need/application.
When a test is violated, it is up to the user to determine the special cause. Test violations are not necessarily negative in nature
as they may indicate either a favorable or adverse shift in a
process. Or they just might indicate an abnormal event that the
process failed to handle.

Results

What is the variation trying to tell us about


a process, about the people in the process?
W. Edwards Deming
During their interviews with Cvengros, leaders from both hospitals (rather proudly) claimed improvements in the accuracy of
the EDDproviding examples to Cvengros (see Table 2).
Table 2 EDD Accuracy Rate for Past 4 Weeks
Week Ending

Penner

Memorial

09/07/2014

35.5%

43.0%

09/14/2014

43.2%

44.3%

09/21/2014

40.2%

45.3%

09/28/2014

48.0%

45.2%

Cvengros knew her control chart analysis would show


whether or not they were reacting to normal variation or
whether their actions had resulted in a statistically significant
favorable change.
Even though it was only one data point, Cvengros felt her analysis could be a proxy on the hospitals willingness to change and
adapt. In other words, she would have a quantitative way to
assess whether the actions of the healthcare leaders back their
words on continuous improvement.

ASQ

For More Information

To contact the author of this case study, email Jack Boepple


at j-boepple@kellogg.northwestern.edu.

To view this and other case studies, visit the ASQ


Knowledge Centers Case Studies landing page at asq.org/
knowledge-center/case-studies.

References
1. HCAHPS, http://hcahpsonline.org/home.aspx.
2. Medicare Hospital Compare, http://www.medicare.gov/
hospitalcompare/.
3. Institute for Healthcare Improvement. How-to Guide:
Multidisciplinary Rounds, http://www.ihi.org/resources/
Pages/Tools/HowtoGuideMultidisciplinaryRounds.aspx.
4. Curaspan. Estimating the Date of Discharge: Five Reasons
to Do It, http://connect.curaspan.com/blog/estimating-datedischarge-five-reasons-do-it.
5. Health Affairs. Improving Care Transitions, http://www.
healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76.
6. iSixSigma. Common Cause Variation, http://www.
isixsigma.com/dictionary/common-cause-variation;
Variation (Special Cause), http://www.isixsigma.com/
dictionary/variation-special-cause/.
7. Wikipedia. Statistical process control, http://en.wikipedia.
org/wiki/Statistical_process_control.
8. Wikipedia. Run Chart, http://en.wikipedia.org/wiki/
Run_chart.

About the Author


Jack Boepple is a process improvement professional and adjunct
professor at the Kellogg School of Management. He received
his Project Management Professional (PMP) certification in
1999, his ASQ Six Sigma Black Belt certification (CSSBB) in
2007, his ASQ Manager of Quality/Organizational Excellence
certification (CMQ/OE) in 2007, and his Professional in
Healthcare Quality (CPHQ) certification in 2015. He served as
an examiner for the Baldrige Performance Excellence Program
from 20082010 and 2012.

www.asq.org

Page 6 of 6

También podría gustarte