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.
- The list below shows the number of responses based on questions with ratings for Great, Good, OK, Fair, Poor, and No Response out of a total of 40.
- Facility and Convenience
Hours of Operations – 10, 17, 3, 0, 10, and 0
Convenience of location – 10, 15, 5, 3, 3, and 4
Cleanliness – 11, 14, 8, 4, 3, and 0
Waiting time in reception area – 9, 16, 0, 4, 11, and 0
Comfort while waiting – 20, 10, 5, 5, 0, and 0
Staff
Explained procedure – 17, 9, 8, 0, 6, and 0
Questions answered – 11, 15, 7, 2, 3, and 2
Friendly and helpful – 21, 5, 5, 7, 2, and 0
- Knowledgeable and professional – 6, 21, 4, 3, 3, and 0
- Modesty respected – 12, 14, 8, 0, 6, and 0
- Confidentiality respected (HIPAA) – 10, 10, 14, 5, 1, and0
- Overall Satisfaction
- Overall impression of visit – 30, 0, 5, 3, 2, and 0
Willingness to return – 31, 0, 9, 0, 0, and 0
Likelihood of referring to others – 32, 0, 4, 3, 1, and 0
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
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
How to solve
HSA3383 Deliverable 5 – Statistics and Quality Methods Deliverable 5 – Statistics and Quality Methods
Introduction:
In this scenario, I have been hired as a medical professor to design and implement a Quality Improvement Plan for Chaparral Regional Hospital. The CEO has requested employee training on Quality Improvement, and I have conducted an initial survey of patient satisfaction. The task at hand is to analyze the initial data and provide an explanation of each statistical result in a memo. Additionally, an agenda for a meeting with the supervisor and fellow department heads needs to be created, focusing on the data analysis and its use in Quality Improvement plans.
Answer to question 1:
The percentage of respondents who responded with a 5 (Great) on “Overall impression of the visit” can be calculated by dividing the number of responses rated as 5 by the total number of responses for this question and then multiplying by 100.
For this scenario, the percentage would be calculated as follows:
Number of responses rated as 5 on “Overall impression of the visit” = 30
Total number of responses for this question = 40
Percentage = (30/40) * 100 = 75%
Answer to question 2:
The percentage of respondents who responded with a 2 (Fair) or 1 (Poor) on “Overall impression of the visit” can be calculated by adding the number of responses rated as 2 and 1 and dividing it by the total number of responses for this question. Then multiply by 100 to get the percentage.
Number of responses rated as 2 (Fair) on “Overall impression of the visit” = 3
Number of responses rated as 1 (Poor) on “Overall impression of the visit” = 2
Total number of responses for this question = 40
Percentage = ((3+2)/40) * 100 = 12.5%
Answer to question 3:
The percentage of respondents who responded with a 5 (Great) on “Willingness to return” can be calculated in the same way as question 1, by dividing the number of responses rated as 5 by the total number of responses for this question and then multiplying by 100.
Number of responses rated as 5 on “Willingness to return” = 31
Total number of responses for this question = 40
Percentage = (31/40) * 100 = 77.5%
Answer to question 4:
The percentage of respondents who responded with less than 5 on “Willingness to return” can be calculated by subtracting the percentage calculated in question 3 (percentage of respondents who responded with a 5) from 100.
Percentage of respondents who responded with a 5 on “Willingness to return” = 77.5%
Percentage of respondents who responded with less than 5 on “Willingness to return” = 100% – 77.5% = 22.5%
Answer to question 5:
To determine the indicator in the area of “Facility and Convenience” with the highest percentage of 5 (Great) responses, each indicator’s percentages need to be calculated. The indicator with the highest percentage would have the maximum value among these percentages, and the indicator with the lowest percentage would have the minimum value.
The percentages for each indicator in the area of “Facility and Convenience” are as follows:
1. Hours of Operations: 10%
2. Convenience of location: 15%
3. Cleanliness: 14%
4. Waiting time in reception area: 16%
5. Comfort while waiting: 50%
The indicator with the highest percentage of 5 (Great) responses is “Comfort while waiting” with 50%. The indicator with the lowest percentage would be “Hours of Operations” with 10%.
Answer to question 6:
To determine the indicator in the area of “Staff” with the highest and lowest percentage of 5 (Great) responses, a similar process to question 5 needs to be followed.
The percentages for each indicator in the area of “Staff” are as follows:
1. Explained procedure: 21%
2. Questions answered: 15%
3. Friendly and helpful: 35%
4. Knowledgeable and professional: 31%
5. Modesty respected: 28%
6. Confidentiality respected (HIPAA): 25%
The indicator with the highest percentage of 5 (Great) responses is “Explained procedure” with 21%. The indicator with the lowest percentage would be “Confidentiality respected (HIPAA)” with 25%.
Answer to question 7:
To calculate the mean waiting time in the reception area, the sum of all wait times needs to be divided by the total number of responses.
Wait time before being checked in at Reception:
Number of responses with wait time 4 – 10 minutes = 10
Number of responses with wait time 16 – 15 minutes = 16
Number of responses with wait time 8 – 20 minutes = 8
Number of responses with wait time 12 – 25 minutes = 12
Total number of responses for this question = 46
Mean waiting time in the reception area = (10*10 + 16*15 + 8*20 + 12*25) / 46 = 15.65 minutes (approximately)
Answer to question 8:
To calculate the mean waiting time to see a healthcare professional, the same process as in question 7 is followed, but using the data for wait time before being seen by a healthcare professional.
Wait time before being seen by a healthcare professional:
Number of responses with wait time 2 – 10 minutes = 2
Number of responses with wait time 6 – 15 minutes = 6
Number of responses with wait time 10 – 20 minutes = 10
Number of responses with wait time 22 – 25 minutes = 22
Total number of responses for this question = 40
Mean waiting time to see a healthcare professional = (2*10 + 6*15 + 10*20 + 22*25) / 40 = 19.5 minutes (approximately)
Overall, analyzing these statistics can help identify areas of improvement, such as addressing low satisfaction rates and long waiting times. This data can be used to develop targeted quality improvement initiatives aimed at enhancing patient experience, reducing wait times, and improving various aspects of the facility and staff performance.
