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.

Question
Great5
Good4
OK3
Fair2
Poor1
No Response
Total

Facility and Convenience

Hours of Operations
10
17
3
0
10
0
40

Convenience of location
10
15
5
3
3
4
40

Cleanliness
11
14
8
4
3
0
40

Waiting time in reception area
9
16
0
4
11
0
40

Comfort while waiting
20
10
5
5
0
0
40

Staff

Explained procedure
17
9
8
0
6
0
40

Questions answered
11
15
7
2
3
2
40

Friendly and helpful
21
5
5
7
2
0
40

Knowledgeable and professional
6
21
4
3
3
0
40

Modesty respected
12
14
8
0
6
0
40

Confidentiality respected (HIPAA)
10
10
14
5
1
0
40

Overall Satisfaction

Overall impression of visit
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 responding
Wait time before being checked in at Reception

4
10 minutes

16
15 minutes

8
20 minutes

12
25 minutes

Number responding
Wait time before being seen by a healthcare professional

2
10 minutes

6
15 minutes

10
20 minutes

22
25 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 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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