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The Joint Commission Accreditation of Health Care Organizations (JCAHO) monitors and evaluates health care providers according to strict standards and guidelines

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The Joint Commission Accreditation of Health Care Organizations (JCAHO) monitors and evaluates health care providers according to strict standards and guidelines. Improvement in the quality of care is a principal concern. Hospitals are required to identify and monitor important quality indicators that affect patient care and establish "thresholds for evaluation" (TFEs), which are levels at which special investigation of problems should occur. TFEs provide a means of focusing attention on nonrandom errors (that is, spe- cial causes of variation). A logical way to set TFEs is through control charts.

Suppose that Hallenvale Hospital collects monthly data on the number of infections after surgeries. These data are shown in TFEs worksheet in the Excel file CaseData. Hospital administrators are concerned about whether the high percentages of infections (such as 1.76 percent in month 12) are caused by factors other than randomness.

Case 3 Questions:

1.      Using the data in theTFEs worksheet in the Excel file CaseData, what is the average percentage of infections?

2.      Construct an appropriate control chart, compute the upper and lower control limits, plot the data on a control chart, and determine if the process is in statistical control. Based on your analysis, what action, if any, should management take?

3.      What TFE should management use to monitor future data?