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 Great 5 Good 4 OK 3 Fair 2 Poor 1 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? ...

1. 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
Great
5
Good
4
OK
3
Fair

2. 2
Poor
1
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

3. 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

4. 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

5. 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

6. 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

7. 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:
a. Explain each statistical example
b. How that data would be used
c. The majority of the agenda should be focused on data
analysis and its use in QI plans
Grading Rubric
F
F
C
B
A
0
1
2
3
4

8. No Pass
No Pass
Competence
Proficiency
Mastery
Not Submitted
Does not demonstrate comprehensive knowledge or skill
Demonstrates comprehensive knowledge or skills
Demonstrated mastery exceeds level of comprehensive
knowledge or skills
Uses mastery of competency to devise alternate solutions and
create new value
Not Submitted
No format is provided for the training memo presentation.
Provides a formatted memo containing bullet points for training.
Provides a formatted memo containing bullet points for training
and supporting structure.
Executes an appropriate format for a memo containing bullet
points for training and a supporting structure.
Not Submitted
No noticeable attempt was made to create an organized agenda.
Creates an agenda addressing the key topics.
Creates an agenda addressing the key topics with supporting
details and questions.
Executes an agenda that includes supporting topics and related
questions.
Not Submitted
No noticeable attempt to identify the appraisal of validity
factors when measuring quality.
Identifies how validity factors are used when measuring quality.
Identifies how validity factors are used when measuring quality
and provides supporting details.
Correctly identifies how validity is related to measuring quality
and thoroughly discusses supporting details.
Not Submitted
No noticeable attempt to identify the appraisal of reliability

9. factors when measuring quality.
Identifies how reliability factors are used when measuring
quality.
Identifies how reliability factors are used when measuring
quality and provides supporting details.
Correctly identifies how reliability is related to measuring
quality and thoroughly discusses supporting details.
Not Submitted
No noticeable attempt to provide sample questions for a QI
survey.
Provides questions that would be asked during a QI survey.
Correctly identifies questions that would be asked during a QI
survey.
Executes supporting questions that would be asked on a QI
survey.