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 Deliverable 5 – Statistics and Quality Methods

Competency

Apply statistics to different quality methods in healthcare.

Course Scenario

Chaparral Regional Hospital is a small, urban hospital of approximately 60 beds, and offers the following:

Emergency room services
Intensive care
Surgical care
Obstetrics
Diagnostic services
Some rehabilitation therapies
Inpatient pharmacy services
Geriatric services and
Consumer physician referral services

Recently, the CEO has been hearing complaints from both patients and staff. You have been hired to design and implement a Quality Improvement Plan to help uncover quality problems and satisfactorily resolve them.

Scenario Continued

Your CEO has requested that you provide employee training on Quality Improvement. You have done an initial survey of patient satisfaction, and the CEO has asked you to explain how the data will be analyzed, using this initial data.

Given the variety of complaints coming from both employees and patients, it is critical for everyone to understand the importance of conducting the survey and obtaining solid data.

QuestionGreat

5Good

4OK

3Fair

2Poor

1No ResponseTotalFacility and Convenience       Hours of Operations10173010040Convenience of location1015533440Cleanliness1114843040Waiting time in reception area9160411040Comfort while waiting2010550040Staff       Explained procedure179806040Questions answered1115723240Friendly and helpful215572040Knowledgeable and professional621433040Modesty respected1214806040Confidentiality respected (HIPAA)10101451040Overall Satisfaction       Overall impression of visit300532040Willingness to return310900040Likelihood of referring to others320431040

Respondents Knowledgeable and professional621433040Modesty respected1214806040Confidentiality respected (HIPAA)10101451040Overall Satisfaction       Overall impression of visit300532040Willingness to return310900040Likelihood of referring to others320431040

Respondents were also asked about their wait times. Here is the data on wait times:

Number responding Wait time before being checked in at Reception

4 10 minutes

16 15 minutes

8 20 minutes

12 25 minutes

Number respondingWait time before being seen by a healthcare professional210 minutes615 minutes1020 minutes2225 minutes

Instructions

You are to create an agenda for the training and a memo with bullet points to present the statistical analysis of the initial data. The memo should include an explanation of each of the statistical results. In particular, you should be able to explain what the results mean to the facility.

Determine the percentages of the following:

Percent who responded with a 5 (Great) on “Overall impression of the visit”
Percent who responded with a 2 (Fair) or 1 (Poor) on “Overall impression of the visit”
Percent who responded with a 5 (Great) on “Willingness to return”
Percent who responded with less than 5 on “Willingness to return”
In the area of “Facility and Convenience,” which indicator had the highest percentage of 5 (Great) responses? Which had the lowest?
In the area of “Staff,” which indicator had the highest percentage of 5 (Great) responses? Which had the lowest?

What is the mean waiting time in the reception area?

What is the mean waiting time to see a healthcare professional?

Microsoft Word has many memo templates. In your memo, be sure to address each statistical analysis and what it means to the facility. Why ask these questions? How could the data be used for quality improvement?

NOTE – APA formatting, and proper grammar, punctuation, and form required.

An agenda can set the tone for a meeting. It is an important tool to ensure meetings are staying on track and meeting all of the objectives. Create an detailed meeting agenda for a meeting you will hold with your supervisor and fellow department heads discussing your findings (Hint: Microsoft Word has many agenda templates).

Make sure to include the following in the agenda:

Explain each statistical example
How that data would be used
The majority of the agenda should be focused on data analysis and its use in QI plans

Grading Rubric

FFCBA01234No PassNo PassCompetenceProficiencyMasteryNot SubmittedDoes not demonstrate comprehensive knowledge or skillDemonstrates comprehensive knowledge or skillsDemonstrated mastery exceeds level of comprehensive knowledge or skillsUses mastery of competency to devise alternate solutions and create new valueNot SubmittedNo format is provided for the training memo presentation.Provides a formatted memo containing bullet points for training.Provides a formatted memo containing bullet points for training and supporting structure.Executes an appropriate format for a memo containing bullet points for training and a supporting structure.Not SubmittedNo noticeable attempt was made to create an organized agenda.Creates an agenda addressing the key topics.Creates an agenda addressing the key topics with supporting details and questions.Executes an agenda that includes supporting topics and related questions.Not SubmittedNo noticeable attempt to identify the appraisal of validity factors when measuring quality.Identifies how validity factors are used when measuring quality.Identifies how validity factors are used when measuring quality and provides supporting details.Correctly identifies how validity is related to measuring quality and thoroughly discusses supporting details.Not SubmittedNo noticeable attempt to identify the appraisal of reliability factors when measuring quality.Identifies how reliability factors are used when measuring quality.Identifies how reliability factors are used when measuring quality and provides supporting details.Correctly identifies how reliability is related to measuring quality and thoroughly discusses supporting details.Not SubmittedNo noticeable attempt to provide sample questions for a QI survey.Provides questions that would be asked during a QI survey.Correctly identifies questions that would be asked during a QI survey.Executes supporting questions that would be asked on a QI survey.

SCIENCE
HEALTH SCIENCE
NURSING

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