Month Falls Bed Days Fall Rate Practice

M-20 6 612 0.980 1. Run chart A1:B22 Falls

A 5 719 0.695 2. Run chart of A1:A22,D1:D22 Fall Rate
M 7 655 1.069 3. c Chart of A1:B22 Falls
J 3 497 0.604 4. XmR chart of A1:A22,D1:D22 Falls Rate
J 4 553 0.723 Use QIMacros templates
A 6 649 0.924 5. Copy data into Run Chart Template
S 2 502 0.398 6. Copy data into c Chart Template
O 5 514 0.973 7. Copy data into XmR Template
N 4 507 0.789
D 2 443 0.451
J-21 4 549 0.729
F 3 412 0.728
M 7 632 1.108
A 4 589 0.679
M 5 508 0.984
J 7 679 1.031
J 6 982 0.611
A 8 802 0.998
S 10 978 1.022
O 7 812 0.862
N 9 917 0.981
 Month Measure Practice
Jan 83 1. Run Chart (Median) A1:B12
Feb 80
Mar 81
Apr 84
May 83
Jun 85
Jul 68
Aug 87
Sep 89
Oct 92
Nov 91
 Timely
Reperfusion in ED Practice
(Percent)
J-20 32 1. Run Chart (Median) A1:B25
Feb 23
Mar 32
Apr 38
May 35
Jun 35
Jul 40
Aug 21
Sep 38
Oct 26
Nov 22
Dec 27
Jan 23
Feb 32
Mar 36
Apr 29
May 38
Jun 42
Jul 39
Aug 36
Sep 50
Oct 48
Nov 39
Dec 44
 Timely
Reperfusion Median
in ED
J-20 32 35.5
Feb 23 35.5
Mar 32 35.5
Apr 38 35.5
May 35 35.5
Jun 35 35.5
Jul 40 35.5
Aug 21 35.5
Sep 38 35.5
Oct 26 35.5
Nov 22 35.5
Dec 27 35.5
Jan 23 35.5
Feb 32 35.5
Mar 36 35.5
Apr 29 35.5
May 38 35.5
Jun 42 35.5
Jul 39 35.5
Aug 36 35.5
Sep 50 35.5
Oct 48 35.5
Nov 39 35.5
Dec 44 35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
35.5
 Returns Surgeries Practice
F 20 14 492 1. p Chart A1:C13
M 10 391
A 12 498 Use QI Macros Templates
M 21 608 2. Copy data into p Chart Template
J 10 535
J 8 488
A 8 443
S 13 519
O 8 615
N 13 480
D 8 533
J21 12 257
 Harm
Month Hospital Shift Rate/1000
Pt Days
Jan Hosp1 D 1.972
Jan Hosp1 E 1.030
Jan Hosp1 N 0.894
Jan Hosp2 D 1.654
Jan Hosp2 E 0.84
Jan Hosp2 N 0.32
Feb Hosp1 D 3.060
Feb Hosp1 E 0.870
Feb Hosp1 N 1.128
Feb Hosp2 D 2.366
Feb Hosp2 E 1.393
Feb Hosp2 N 0.938
Mar Hosp1 D 3.960
Mar Hosp1 E 1.033
Mar Hosp1 N 1.828
Mar Hosp2 D 2.723
Mar Hosp2 E 1.205
Mar Hosp2 N 1.606
Apr Hosp1 D 3.960
Apr Hosp1 E 1.421
Apr Hosp1 N 0.856
Apr Hosp2 D 2.13
Apr Hosp2 E 1.46
Apr Hosp2 N 1.11
May Hosp1 D 4.960
May Hosp1 E 1.098
May Hosp1 N 1.360
May Hosp2 D 2.721
May Hosp2 E 2.433
May Hosp2 N 1.348
June Hosp1 D 4.960
June Hosp1 E 1.098
June Hosp1 N 1.360
June Hosp2 D 2.721
June Hosp2 E 2.433
June Hosp2 N 1.348
 Month % Sat (X) Target (Ave) 88.296
J-19 82 Goal 85
F 79
M 84
A 82
M 92
J 80
J 94
A 78
S 83
O 84
N 92
D 84
J-20 89
F 88
M 93
A 84
M 98
J 92
J 87
A 94
S 93
O 95
N 91
D 84
J-21 95
F 92
M 95
 Practice
1. Run Chart of A1:B28
2. CUSUM Chart of A1:B28 using E1 as target
3. CUSUM Chart of A1:B28 using 85 as target
 Wait Time and Satisfaction Data from Four Clinics
Clinic 1 Clinic 2 Clinic 3
Average wait Average wait Average wait
Average Average Average
Week time time time
patient rating patient rating patient rating
(Minutes) (Minutes) (Minutes)
1 40 3.98 40 3.43 40 4.27
2 32 4.53 32 3.93 32 4.62
3 52 4.21 52 3.63 52 1.63
4 36 3.6 36 3.62 36 4.45
5 44 3.84 44 3.37 44 4.1
6 56 3.02 56 3.95 56 3.58
7 24 4.38 24 4.94 24 4.96
8 16 5.87 16 6.45 16 5.31
9 48 2.58 48 3.44 48 3.93
10 28 5.59 28 4.37 28 4.79
11 20 5.16 20 5.63 20 5.14

Scatter Plot B3:C14 Scatter Plot D3:E14 Scatter Plot F3:G14

Clinics
Clinic 4
Average wait
Average
time
patient rating
(Minutes)
32 4.71
32 5.12
32 4.15
32 3.58
32 3.77
32 4.48
32 5.38
76 1.75
32 5.22
32 4.05
32 4.56

Scatter Plot H3:I14

 Infectious
Month Waste (#) per
Patient Day
J-19 6.8 1. Run XmR (ImR) chart of A1:B22 using Control Chart Wizard
J 6.7
A 6.86 Use QI Macros Templates
S 6.63 2. Copy data into XmR Chart Template
O 6.86
N 7.61
D 6.99
J-20 7.48
F 6.96
M 7.22
A 7.27
M 7.19
J 7.58
J 7.46
A 6.6
S 6.97
O 7.05
N 7.41
D 7.91
J-21 6.38
F 6.69
 Test 1 Test2 Test 3 Test 4 Test 5 Test 6
7-Jun 105 54 79 49 31
8-Jun 50 105 85
9-Jun 58 26 38
10-Jun 67 52 92 46
11-Jun 73 59 62
12-Jun 57 64 24
13-Jun 78 96 107 72 27 43
14-Jun 76 49 40
15-Jun 18 60 39
16-Jun 39 45 35
17-Jun 86 27 91 49 23 65
18-Jun 32 47 57
19-Jun 70 56 40 34
20-Jun 39 34 146
 Health Care Data Guide 1st Edition pg. 160

Practice
1. XbarS chart of A1:G15
Use QI Macros Templates
2. Copy data into XBarS Chart Template
 Patients Charts
Month
Harmed Reviewed
Health Care Data Guide 1st Edition pg. 167
F20 9 20
M 5 20 1. Run p Chart on A1:C13
A 8 20 Use QI Macros Templates
M 10 20 2. Copy data into p Chart Template
J 11 20
J 9 20
A 7 20
S 8 20
O 10 20
N 5 20
D 9 20
J21 8 20
 Patients
Month Discharges
Readmitted Health Care Data 1st Edition Guide pg. 170
J-20 19 688 1. p Chart of A1:C27
Feb 12 643 Use QI Macros Templates
Mar 10 411 2. Copy data into p Chart Template
Apr 23 678
May 20 999
Jun 16 735
Jul 7 647
Aug 18 678
Sep 14 312
Oct 16 717
Nov 12 680
Dec 14 733
Jan 8 670
Feb 18 703
Mar 19 638
Apr 16 702
May 10 682
Jun 22 578
Jul 11 686
Aug 16 663
Sep 21 614
Oct 19 711
Nov 15 678
Dec 26 690
Jan 22 392
Feb 37 860
 S. Aureus S. Aureus
Hospital MRSA Hospital MRSA
Infections Infections Sorted
South 59 87 Mid 22 27
North 50 60 Central 22 39
East 32 53 Regional 30 41
West 48 94 Capital 41 44
Mid 22 27 University 30 44
Capital 41 44 General 26 52
Palins 33 59 East 32 53
City 39 68 Palins 33 59
Central 22 39 Community 22 59
University 30 44 North 50 60
General 26 52 City 39 68
Community 22 59 South 59 87
Regional 30 41 West 48 94
Health Care Data Guide 1st Edition pg. 171
1. p Chart of A1:C14
2. p Chart of E1:G14
Use QI Macros Templates
3. Copy data into p Chart Template
 Number
Number
prescribed
Organization of Cases
ACEI or SRB
LVSD
for LVSD
A 20 14 1. Run a p Chart on A1:C20
F 26 18 Use QI Macros Templates
D 29 20 2. Copy data into p Chart Template
G 31 28
J 40 32
S 47 31
K 66 60
H 68 58
O 77 76
L 85 74
C 99 74
R 140 129
E 150 138
N 155 128
Q 190 168
P 201 195
B 252 189
M 280 254
I 507 427
 Month Needlesticks Health Care Data Guide 1st Edition pg. 177
J-20 6
Feb 2 1. Run a c Chart on A1:B25
Mar 4 Use QI Macros Templates
Apr 8 2. Copy data into c Chart Template
May 5
Jun 4
Jul 23
Aug 7
Sep 3
Oct 5
Nov 12
Dec 7
Jan 10
Feb 5
Mar 9
Apr 4
May 3
Jun 2
Jul 3
Aug 1
Sep 3
Oct 4
Nov 3
Dec 1
 Flash Number of
Week Health Care Data Guide 1st Edition pg. 180
Sterilizations Surgeries
1 42 84 1. Run p Chart A1:C45
2 47 146 Use QI Macros Templates
3 51 91 2. Copy data into p Chart Template
4 45 106
5 36 88
6 34 126
7 37 81
8 49 86
9 39 83
10 46 77
11 28 78
12 46 108
13 34 72
14 44 131
15 41 83
16 44 126
17 48 139
18 22 75
19 48 114
20 44 84
21 45 127
22 43 94
23 33 72
24 43 130
25 19 81
26 19 82
27 22 127
28 19 76
29 26 81
30 11 67
31 29 103
32 13 75
33 15 84
34 37 78
35 38 85
36 47 131
37 32 83
38 45 98
39 36 104
40 26 82
41 37 109
42 39 107
43 39 88
44 36 94
 Number of Units/1000 Number
Month
ADEs Doses of Doses u Chart Health Care Data Guide 1st Edition pg. 181
M-20 50 17.11 17110 1. u Chart of A1:C27
Apr 44 12.14 12140 Use QI Macros Templates
May 47 17.99 17990 2. Copy data into u Chart Template
Jun 32 14.98 14980
Jul 51 21.98 21980
Aug 57 15.32 15320
Sep 43 12.99 12990
Oct 61 19.76 19760
Nov 30 8.67 8670
Dec 32 12.68 12680
Jan 41 20.33 20330
Feb 57 18.55 18550
Mar 31 14.31 14310
Apr 11 9.73 9730
May 3 11.47 11470
Jun 6 5.39 5390
Jul 9 21.7 21700
Aug 3 6.37 6370
Sep 10 22.5 22500
Oct 8 11.17 11170
Nov 9 10.91 10910
Dec 4 8.76 8760
Jan 9 11.14 11140
Feb 10 12.3 12300
Mar 13 17.17 17170
Apr 2 8.91 8910
 Clinic Complaints Visits/1000 Visits
u Chart Health Care Data Guide 1st Edition pg. 183
A 17 18.0 18003 1. u Chart of A1:C18
B 11 13.5 13542 Use QI Macros Templates
C 21 22.9 22891 2. Copy data into u Chart Template
D 21 12.1 12111
E 18 16.2 16167
F 21 43.7 43689
G 31 21.0 21007
H 22 17.5 17532
I 15 18.2 18209
J 11 14.7 14705
K 31 19.0 19024
L 25 18.9 18933
M 26 14.3 14328
N 32 20.0 19999
O 20 18.6 18632
P 17 15.4 15421
Q 26 19.3 19333
 Patient
Complaints Pareto Health Care Data Guide 1st Edition pg. 336
Pain Management 73
Respect 62
Information 21
Emontional Support 11
Care Coordination 9
Comfort 6
Transition 3
Family Involvement 2
Other 1
de 1st Edition pg. 336
 Month % Sat (S) Note: This is the same data as pg. 102
J-20 82 1. Run a CUSUM Chart on this data
F 79
M 84
A 82
M 92
J-20 80
J-20 94
A 78
S 83
O 84
N 92
D 84
J-21 89
F 88
M 93
A 84
M 98
J-21 92
J-21 87
A 94
S 93
O 95
N 91
D 84
J-22 95
F 82
M 95
 Month Costs Charges Profit Practice
J-20 161 289 102 1. Run Hotelling T2 chart on A1:D46
F 169 311 105 2. Run XmR/ImR charts on A1:B46, C1:C46, D1:D46
M 155 282 109 Use QI Macros Templates
A 172 305 110 3. Copy data into XmR Chart Dashboard
M 180 327 115
J 163 296 97
J 175 312 98
A 153 268 96
S 171 289 87
O 180 316 116
N 161 279 83
D 152 294 110
J-21 182 316 93
F 173 316 129
M 170 328 130
A 179 321 106
M 172 309 124
J 168 299 74
J 158 284 105
A 180 322 83
S 162 284 79
O 188 339 113
N 172 311 137
D 168 299 98
J-22 157 296 119
F 148 308 137
M 161 328 167
A 164 335 190
M 170 332 153
J 140 280 162
J 163 330 166
A 168 324 176
S 141 285 147
O 144 295 106
N 136 268 76
D 150 295 126
J-23 131 276 94
F 133 279 127
M 180 338 132
A 191 332 114
M 185 338 124
J 167 309 109
J 152 268 65
A 169 301 85
S 160 270 78
 Managing
Month Members Percentage
by Phone
J-20 3852 8755 44.0
F-20 4100 9800 41.8
M-20 7083 17000 41.7
A-20 7339 16400 44.8
M-20 9406 19500 48.2
J-20 9310 19800 47.0
J-20 7250 21200 34.2
A-20 10400 22300 46.6
S-20 9250 21600 42.8
O-20 9950 20500 48.5
N-20 9846 18700 52.7
D-20 9854 18900 52.1
J-21 8034 14300 56.2
F-21 8162 14800 55.1
M-21 8122 14500 56.0
A-21 8200 14600 56.2
 Practice
1. Run p Chart on A1:C17
2. Run p' Laney Chart on A1:C17
3. Run XmR Chart on A1:A17, D1:D17
Use QI Macros Templates
4. Copy data into p' Chart Template
 # in # with
Clinic Percentage
Registry Goals
I 180 83 46.1
B 200 160 80.0
H 250 47 18.8
L 315 15 4.8
K 334 16 4.8
C 336 188 56.0
N 592 0 0.0
M 800 0 0.0
E 804 365 45.4
A 1050 829 79.0
J 1200 99 8.3
D 1265 469 37.1
F 1580 597 37.8
G 1845 426 23.1
 Practice
1. Run p Chart on A1:C15
2. Open p Chart template and use the same data in the p' Chart worksheet
3. Run an XmR Chart on A1:A15,D1:D15
Use QI Macros Templates
4. Copy data into p Chart Template
5. Copy data into XmR Chart Template
 Total ADEs (8 Doses/
Month
Hospitals) 1000 Health Care Data Guide 1st Edition pg. 290
J-20 1129 70.8 1. u Chart of A1:C19
F 1194 80.15 Use QI Macros Templates
M 1158 75.35 2. Copy data into u Chart Template
A 1199 76.06
M 1077 74.98
J 1135 75.96
J 1150 70.8
A 1206 80.47
S 1169 76.68
O 1193 81.88
N 1224 75.29
D 1155 78.54
J-21 1181 79.73
F 1119 80.65
M 1192 81.85
A 1112 77.29
M 1088 74.21
J 1060 75.85
 Dispensed/1,
Hospital/Qtr

Hospital

Doses
ADEs
QTR

OOO
Health Care Data Guide 1st Edition pg. 293
A1 A 1 101 24.254 1. u Chart of A1:E56
A2 A 2 97 23.219 Use QI Macros Templates
A3 A 3 88 25.196 2. Copy data into u Chart Template
A4 A 4 88 24.877
A5 A 5 72 25.484
A6 A 6 100 21.602

B1 B 1 176 11.786
B2 B 2 152 11.55
B3 B 3 192 11.989
B4 B 4 183 11.729
B5 B 5 177 11.685
B6 B 6 191 10.868

C1 C 1 431 26.641
C2 C 2 405 24.228
C3 C 3 409 24.232
C4 C 4 457 27.665
C5 C 5 370 27.405
C6 C 6 338 24.881

D1 D 1 573 35.423
D2 D 2 588 43.458
D3 D 3 585 39.748
D4 D 4 604 40.771
D5 D 5 556 40.498
D6 D 6 598 39.35

E1 E 1 826 44.072
E2 E 2 798 43.714
E3 E 3 855 44.883
E4 E 4 859 49.021
E5 E 5 871 44.225
E6 E 6 678 49.743

F1 F 1 271 17.56
F2 F 2 269 18.869
F3 F 3 264 18.958
F4 F 4 286 17.476
F5 F 5 260 19.003
F6 F 6 265 16.996

G1 G 1 627 40.035
G2 G 2 624 39.457
G3 G 3 629 39.956
G4 G 4 635 41.441
G5 G 5 666 47.249
G6 G 6 607 39.184

H1 H 1 476 25.528
H2 H 2 478 22.505
H3 H 3 503 22.989
H4 H 4 460 22.729
H5 H 5 520 26.685
arial 1 6 483 21.724
 Medication Harm By Cause ADEs by Medication
Communication 1693 Heparin 812
Labeling 1078 Digatalis 570
Name Confusion 612 Coumadin 485
Human Factors 386 Norphine Surface 411
Packaging 382 Insulin 399
Other 277 Potassium Chloride 209
Health Care Data Guide 1st Edition pg. 304

1. Run Pareto Charts of A1:B7 and D1:E7

 Patient
Month %Dissatisfied %Satisfied pg 336
Complaints

A-08 6 26 Pain Management 73

M 3 32 Respect 62
J 7 28 Information 21
J 9 23 Emotional Support 11
A 7 26 Care Coordination 9
S 9 24 Comfort 6
O 8 22 Transition 3
N 5 32 Family Involvement Other 2
D 8 22 1
J-09 6 31
F 8 23
M 7 29
A 4 32
M 5 34
J 5 37
J 3 31
A 5 31
S 2 38
O 5 33
N 2 35
 Clinic
pg. 339
Dissatisfaction
Health Care Data Guide 1st Edition pg. 304
Appointments 82 1. Run Pareto on F1:G10
Respect 42 2. Run Pareto on I1:J14
Lack Information 38
Who Call 35
Wait 17
Hours of Operation 15
Cost 11
Lab Waits 5
Privacy 5
Clinic Appearance 4
Park 4
Other 3
Employees 1
 Infection
Month Rate per 1000
Patient Days
Health Care Data Guide 1st Edition pg. 304
J-20 1.43 1. Run XmR Chart of A1:B34
F 3.46 Use QI Macros Templates
M 1.04 2. Copy data into XmR Chart Template
A 2.32
M 4.39
J 6.83
J 5.41
A 2.12
S 4.71
O 3.3
N 3.5
D 3.13
J-21 3.97
F 2.48
M 2.43
A 4.67
M 5.88
J 6.66
J 2.2
A 4.17
S 6.83
O 2.34
N 6.69
D 4.39
J-22 3.2
F 4.48
M 5.39
A 2
M 4.5
J 1
J 2.3
A 1.1
S 0.6
 Infections
CABGs
Month Health Care Data Guide 1st Edition pg. 389
Performed

J-20 11 101
J 2 104
A 7 98
S 4 81
O 3 96
N 6 80
D 9 85
J-21 7 98
F 9 94
M 5 131
A 9 101
M 3 126
J 0 88
J 3 96
A 9 103
S 4 82
O 10 105
N 3 63
D 8 94
J-22 3 90
F 4 73

M 7 102 After Testing Glucose Protocol

A 0 89
M 2 108
J 4 101
J 0 75
A 1 94
S 2 81
O 0 54
N 2 98
D 3 84
J-23 3 69
F 4 100
M 6 77
 Number
Month Infections
of CABG
Hospital A M-20 5 69 Run p Chart on A1:C28
A 0 61
M 2 71
J 3 73
J 0 56
A 0 65
S 1 58
O 0 32
M 1 60
D 2 59
J-21 2 48
F 3 62
M 6 49

Hospital B M-09 2 33
A 0 28
M 0 37
J 1 28
J 0 19
A 1 29
S 1 23
O 0 22
M 1 29
D 1 25
J-22 1 21
F 1 38
M 1 28
 Qtr Physician Dr-Qtr Infections CABG
Q2-20 K K Q2-20 2 69
Q3 K K Q3 0 66
Q4 K K Q4 1 50
Q1-21 K K Q1-21 1 50
Q2 K K Q2 2 48
Q3 K K Q3 1 42

Q2-20 S S Q2-20 1 64
Q3 S S Q3 0 55
Q4 S S Q4 1 45
Q1-21 S S Q1-21 2 50
Q2 S S Q2 1 43
Q3 S S Q3 1 55

Q2-20 L L Q2-20 1 72
Q3 L L Q3 0 58
Q4 L L Q4 1 56
Q1-21 L L Q1-21 8 59
Q2 L L Q2 4 43
Q3 L L Q3 0 56
 C-Section Deliveries C-Section Deliveries
Q1-20 3 32 A-Q1-20 1 11
Q2 3 13 A-Q2 0 19
Q3 9 36 A-Q3 4 14
Q4 3 36 A-Q4 1 15
Q1-21 6 35 A-Q1-21 3 16
Q2 5 33 A-Q2 2 18
Q3 5 56 A-Q3 2 22
Q4 6 37 A-Q4 2 17
Q1-22 5 22 A-Q1-22 1 10
Q2 5 27 A-Q2 3 9
Q3 5 35 A-Q3 0 13
Q4 3 30 A-Q4 1 17
Q1-23 5 27 A-Q1-23 1 12
Q2 7 39 A-Q2 2 18
Q3 7 53 A-Q3 6 21
Q4 10 58 A-Q4 3 30
Q1-24 5 27 A-Q1-24 3 11
Q2 9 31 A-Q2 3 13
Q3 9 33 A-Q3 3 14
Q4 6 33 A-Q4 1 12
Q1-25 1 27 A-Q1-25 0 9
Q2 4 28 A-Q2 2 13
Q3 7 24 A-Q3 0 10

Z-Q1-20 2 21
Z-Q2 3 24
Z-Q3 5 22
Z-Q4 2 21
Z-Q1-21 3 19
Z-Q2 3 15
Z-Q3 3 34
Z-Q4 4 20
Z-Q1-22 4 12
Z-Q2 2 18
Z-Q3 5 22
Z-Q4 2 13
Z-Q1-23 4 15
Z-Q2 5 21
Z-Q3 1 32
Z-Q4 7 28
Z-Q1-24 2 16
Z-Q2 6 18
Z-Q3 6 19
Z-Q4 4 21
Z-Q1-25 1 18
Z-Q2 2 15
Z-Q3 7 14
Health Care Data Guide 1st Edition pg. 401
1. Run a p Chart of A1:C24
2. Run a p Chart of E1:G48
 CHF Patients Readmissions
Health Care Data Guide 1st Edition pg. 420
Jan-20 290 34 1. Run a p Chart of A1:C25
Feb-20 288 38
Mar-20 293 28
Apr-20 298 31
May-20 305 44
Jun-20 300 23
Jul-20 302 35
Aug-20 299 38
Sep-20 300 42
Oct-20 305 35
Nov-20 308 48
Dec-20 310 29
Jan-21 310 38
Feb-21 314 32
Mar-21 309 44
Apr-21 311 26
May-21 316 38
Jun-21 315 47
Jul-21 310 37
Aug-21 312 28
Sep-21 308 33
Oct-21 307 45
Nov-21 302 30
Dec-21 300 41