statistics and quality methods 6


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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 Great
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
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


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:

  1. Explain each statistical example
  2. How that data would be used
  3. The majority of the agenda should be focused on data analysis and its use in QI plans

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