Methods Inf Med - Control charts in healthcare quality improvement. A systematic review on adherence to methodological criteria.


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JECTIVES: Use of Shewhart control charts in quality improvement (QI) initiatives is increasing. These charts are typically used in one or more phases of the Plan Do Study Act (PDSA) cycle to monitor summaries of process and outcome data, abstracted from clinical information systems, over time. We summarize methodological criteria of Shewhart control charts and investigate adherence of published QI studies to these criteria.METHODS: We searched Medline, Embase and CINAHL for studies using Shewhart control charts in QI processes in direct patient care. We extracted methodological criteria for Shewhart control charts, and for the use of these charts in PDSA cycles, from textbooks and methodological literature.RESULTS: We included 34 studies, presenting 64 control charts of which 40 control charts plotted two phases of the PDSA cycle. The criterion to use 10-35 data points in a control chart was least adhered to (48.4% non-adherence). Other criteria were: transformation of the data in case of a skewed distribution (43.7% non adherence), when comparing data from two phases of the PDSA cycle the Plan phase (the first phase) needs to be stable (40.0% non-adherence), using a maximum of four different rules to detect special cause variation (14.1% non-adherence), and setting control limits at three standard deviations from the mean (all control charts adhered).CONCLUSION: There is room for improvement with regard to the methodological construction of Shewhart control charts used in QI processes. Higher adherence to all methodological criteria will decrease the risk of incorrect conclusions about the process being monitored.

Resumo Limpo

jectiv use shewhart control chart qualiti improv qi initi increas chart typic use one phase plan studi act pdsa cycl monitor summari process outcom data abstract clinic inform system time summar methodolog criteria shewhart control chart investig adher publish qi studi criteriamethod search medlin embas cinahl studi use shewhart control chart qi process direct patient care extract methodolog criteria shewhart control chart use chart pdsa cycl textbook methodolog literatureresult includ studi present control chart control chart plot two phase pdsa cycl criterion use data point control chart least adher nonadher criteria transform data case skew distribut non adher compar data two phase pdsa cycl plan phase first phase need stabl nonadher use maximum four differ rule detect special caus variat nonadher set control limit three standard deviat mean control chart adheredconclus room improv regard methodolog construct shewhart control chart use qi process higher adher methodolog criteria will decreas risk incorrect conclus process monitor

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