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Tools for Grantees: Quality Management Manual


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 III. Step-By-Step Quality Management Guide: Nine Critical Steps

  Graphic of Step 4 Analyze Data
 
• 

Analyze data and review the results.

 
 • 

Identify areas where additional data is required.
If historical data are available, compare for trends.

 
 • 
Display and distribute data to communicate findings and results.
 
 • 
Identify areas for improvement and select a quality improvement project



Graphic: "What to do..." with checked checkbox Analyze data and review the results.  TOP

Once the data is collected, the results should be prepared for analysis and presentation. Data should be presented in the simplest and most understandable form possible in order to determine if an opportunity for improvement exists. To assure confidentiality, data should be reported in the aggregate, by unique identifier or by medical record number so that the information cannot be connected to an individual patient.

Graphic: "What to do..." with checked checkbox Identify areas where additional data is required.  TOP
Graphic:  checked checkbox If historical data are available, compare for trends.

If historical data are available, these should be used to compare trends (e.g., year to year) to help identify opportunities for improvement and assess the severity of the problem. As the data are being analyzed, additional data needs might be identified. It is important, however, to remember that the data were not collected for the purposes of research and a rigorous statistical analysis is not needed.

Graphic: "What to do..." with checked checkbox Display and distribute data to communicate findings and results.  TOP

Graphic displays of data, such as charts and graphs, should be used to convey the results at a glance. Run charts and Pareto charts are two charts that are helpful in displaying data. Run charts are line graphs that plot data over time (Figure 2) while Pareto charts are simple bar charts that rank related categories in decreasing order of occurrence (Figure 3).

Figure 2. Sample of Run Chart
Figure 2: Sample of a Run Chart. Left vertical axis is "Percent % Unkept Appointments" with values from 0-35. Horizontal axis is "Month," beginning with January and at the origin on the left and ending with December on the far right. The plot line begins in January at about 28, falling in February to 22, before rising to about 24 in March and April. In April, the quality improvement measure of making reminder telephone calls to clients was implemented. The plot line falls after April, dipping to about 12 by August. From then, however, the plot line rises slowly to about 19 by the final charted month of December.

[If historical data are available, these should be used to compare for trends to help identify opportunities for improvement and assess the severity of the problem. Run charts are line graphs that plot data over time.]

Figure 3. Sample of Pareto Chart
Figure 3. Sample of a Pareto Chart. The left vertical axis is "Number of Occurrences," with  values ranging from 0-80. Five reasons clients gave for missing an appointment are each represented by a vertical bar with the reason listed inside the bar and the actual number of occurrences printed at the top of the bar. Bars from left to right: Forgot appointment, 80; Didn't feel well, 64; Felt well (so didn't think they needed to come in for appointment), 38; Didn't know they had an appointment, 28; and couldn't get there (transportation problems), 20.

[From these data, we derived several reasons for missed appointments. As a result of these findings, the clinic, in order of priority, implemented a follow-up “Reminder System” to help clients/patients remember their appointment date and time. As a result, client/patient missed appointments decreased significantly].

Graphic: "What to do..." with checked checkbox Identify areas for improvement and select a quality improvement project.  TOP

Once created, the graphic displays can be used to communicate the findings and results and establish a foundation on which to build project-specific quality improvement plans.

 


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