Chapter 2 Introduction

2.1 SPC charts for UDS Medical Measures at CSVS

  • proven Industry standard and tool for QA management;

  • proven and used successfully in health care;

  • focuses on process where process determines product quality as output

  • detects if process is out of balance;

  • thus provides opportunity to cure the process

2.2 SPC CUSUM Charts

  • CUSUM charts pick up on small shifts of less than 1 standard deviation from the mean / target (whereas SPC (standard) control limits are set at 3 sigma).

  • they are good at highlighting that change is underway.

  • need early warning? Then CUSUMS are your friend

  • may use a supplied target, or the mean or median of the data.

2.3 SPC charts for UDS Medical Measures at CSVS

  • Source of data: Azara

  • Report of QA measures for medical providers

  • Start date: October 2020

  • 31 medical providers, as PCP

  • 12 measures (as of Jan 2022:

    • 7 are target-based: Use of Appropriate Medications for Asthma, Diabetes Foot Exam (NQF 0056), Diabetes: Eye Exam (CMS 131v9), Diabetes A1c >9 (CMS 122v9 Modified), Breast Cancer Screening Ages 40-69 (NQF 0031), Cervical Cancer Screening (CMS 124v9), Colorectal Cancer Screening (CMS 130v9)

    • 5 are non-target-based:
      Completed Referrals, Childhood Immunization Status (CMS 117v9), Well-Child Care Visits (3-6 Yrs), Weight Screening / BMI / Nutritional /Physical Activity Counseling (CMS 155v9), Hypertension Controlling High Blood Pressure (CMS 165v9)