Deliverable 5 – Statistics and Quality Methods


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
Diagnostic services
Some rehabilitation therapies 
Inpatient pharmacy services
Geriatric services and
Consumer physician referral services

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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. 

Question       Great      Good     Ok    Fair     Poor     No Response     Total
                          5            4          3        2           1  

Facility and

Hours of            10          17        3        0            10         0                       40 

of location           10         15         5         3         3            4                      40

Cleanliness          11        14         8          4         3            0                     40

Waiting time
reception area       9         16          0          4       11            0                     40

Comfort while
waiting                   20        10         5           5        0             0                    40


Procedure               17        9         8           0         6             0                     40

answered               11          15        7           2        3              2                    40Willingne

Friendly and
Helpful                     21           5       5          7         2              0                     40

and professional       6           21     4          3           3             0                      40

Respected                12         14       8          0            6             0                     40

respected (HIPPA)    10        10       14          5           1             0                      40


Overall Impression
of vist                        30        0         5           3               2             0                   40

Willingness to 
return                         31      0           9          0                0              0                 40

Likelihood of
referring to others       32      0           4           3               1             0                   40

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

Number                  Wait time before being checked in at Reception

  4                            10 minutes

16                             15 minutes

8                                20 minutes

12                               25 minutes

Number                   Wait time before being seen by a healthcare professional 
2                               10 minutes

6                               15 minutes

10                              20 minutes 

22                               25 minutes 

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 a 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

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