Documente Academic
Documente Profesional
Documente Cultură
December 2015
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.
ASQ
www.asq.org
Page 1 of 6
ASQ
Question
Farrell
Memorial
Penner
Mobley
State
Average
National
Average
73%
77%
79%
79%
76%
81%
81%
82%
62%
63%
70%
68%
66%
68%
72%
71%
61%
62%
67%
64%
65%
66%
74%
73%
52%
63%
64%
61%
84%
87%
87%
85%
64%
73%
75%
71%
68%
77%
76%
71%
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
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
Page 3 of 6
NP Chart of 3T
UCL = 25.90
25
20
Sample Count
15
NP = 14.56
10
5
LCL = 3.21
0
1
13
17
21
25
Sample
29
33
37
41
45
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
ASQ
NP Chart of 4s
14
12
1
10
Sample Count
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
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%
ASQ
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.
www.asq.org
Page 6 of 6