Presentation Points
Overview of Quality Reporting Department
Define the problem
Taking measurements
Analyze collected data
Recommend improvements
Discuss control methods
Abstracts for quality auditing from patients with the following conditions:
CHF, AMI, Stroke, CAP, SCIP, VTE, outpatient SCIP, outpatient AMI/Chest Pain
Time from patient discharge to complete chart abstraction is known to exceed requirements.
◦ Board of Directors interested in getting more timely quality reporting.
◦ Patient care cannot adapt quickly if reporting is delayed.
Requirements
Cycle time requested: 30 days
Maximum time: Abstracts completed by the 15th day of the month following discharge. (Maximum 45 days)
Allowances
Papers scanned into charts 2 days
Physicians to sign-off charts 30 days
IS to send reports to QR 30 days
Designed small Ad-hoc query in quality
database system.
Exported needed data to Excel showing date
stamps of discharge date and completed
abstraction date.
July August
ABSTRACTION DATE DISCHARGE_DATE Elapsed Days ABSTRACTION DATE DISCHARGE_DATE Elapsed Days
09/15/2011 07/01/2011 76 10/03/2011 08/03/2011 61
09/07/2011 07/12/2011 57 10/11/2011 08/30/2011 42
09/08/2011 07/07/2011 63 09/30/2011 08/04/2011 57
09/09/2011 07/01/2011 70 10/11/2011 08/11/2011 61
09/09/2011 07/09/2011 62 10/13/2011 08/10/2011 64
09/09/2011 07/13/2011 58 10/18/2011 08/04/2011 75
09/09/2011 07/02/2011 69 10/17/2011 08/17/2011 61
09/23/2011 07/13/2011 72 09/30/2011 08/04/2011 57
09/21/2011 07/07/2011 76 10/14/2011 08/02/2011 73
09/22/2011 07/06/2011 78 10/17/2011 08/02/2011 76
09/07/2011 07/19/2011 50 10/19/2011 08/10/2011 70
09/19/2011 07/08/2011 73 10/17/2011 08/07/2011 71
09/15/2011 07/08/2011 69 10/11/2011 08/05/2011 67
09/09/2011 07/09/2011 62 10/04/2011 08/18/2011 47
09/15/2011 07/16/2011 61 10/04/2011 08/04/2011 61
09/21/2011 07/02/2011 81 10/14/2011 08/01/2011 74
09/19/2011 07/07/2011 74 10/17/2011 08/02/2011 76
09/07/2011 07/05/2011 64 10/13/2011 08/01/2011 73
09/21/2011 07/06/2011 77 10/04/2011 08/10/2011 55
09/08/2011 07/06/2011 64 10/11/2011 08/03/2011 69
Cycle time is outside of required limits
July ◦ Median days 60
◦ Maximum days 84
August ◦ Median days 56
◦ Maximum days 79
Nothing is happening within 30 days
It was determined earlier that IS ran the reports sending the data from the charts into the reporting system only once per month.
Improvement: Increase frequency of reporting to once per week by pulling data from another system.
Cycle time is just outside of required limits
August ◦ Median days 56
◦ Maximum days 79
September ◦ Median days 35
◦ Maximum days 54
21 day increase in cycle time
In order to accurately chart and control this process the following 5 data points must be available to the Quality Department. ◦ Discharge date
◦ Paper charts scanned date
◦ Chart sign-off date
◦ Reports run / available for abstraction date
◦ Abstraction complete date
Currently only discharge date, and abstraction date are available to Quality Reporting.
Days Elapsed 20 7 6 2
Percent 57.1 20.0 17.1 5.7
Cum % 57.1 77.1 94.3 100.0
C1
Pape
rs sca
nned
into cha
rt
Abstra
ction
Repo
rts G
enerated
Char
t Sign-
off
40
30
20
10
0
100
80
60
40
20
0
Da
ys E
lap
se
d
Pe
rce
nt
Pareto Chart by Department
Days Elapsed 20 7 5 3
Percent 57.1 20.0 14.3 8.6
Cum % 57.1 77.1 91.4 100.0
C1
Pape
rs sca
nned
into cha
rt
Chart S
ign-off
Repo
rts G
enerated
Abstraction
40
30
20
10
0
100
80
60
40
20
0
Da
ys E
lap
se
d
Pe
rce
nt
Pareto Chart by Department
121110987654321
70
60
50
40
30
Weeks
Sam
ple
Mean
__X=36.55
LC L=33.11
UC L=39.99
121110987654321
20
15
10
5
0
Weeks
Sam
ple
Ran
ge
_R=5.97
UC L=12.61
LC L=0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
11
Control Chart of Weekly Cycle Times
4321
50
40
30
Weeks
Sam
ple
Mean
__X=37.06
UC L=40.19
LC L=33.94
4321
16
12
8
4
0
Weeks
Sam
ple
Ran
ge
_R=8.38
UC L=15.63
LC L=1.14
1
1
1
Xbar-R Chart of September Only
Institute checks of process using newly available data points to check for future conformance, and greatest bottleneck.
Six Sigma Future Project: ◦ Collect future data based on 5 data points, create
and maintain control and distribution and pareto charts.
◦ Identify any processes that need improvement to eliminate or smooth saw-tooth pattern based on future data collection.
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