Chapter 3 SPC-based QA: A Presentation

3.1 Paradigm

Statistical Process Control as the cornerstone of QA/QI, Peer Review, and clinical performance evaluations: focus on process management

3.1.1 What is Statistical Process Control?

“SPC stands for statistical process control. Statistical Process Control is a scientific visual method used to monitor, control and improve processes by eliminating special cause variation from manufacturing, service and financial processes.”

“Statistical process control (SPC) is a method of quality control which employs statistical methods to monitor and control a process. This helps to ensure that the process operates efficiently, producing more specification-conforming products with less waste”

“Statistical process control (SPC) is defined as the use of statistical techniques to control a process or production method. SPC tools and procedures can help you monitor process behavior, discover issues in internal systems, and find solutions for production issues.”

3.1.2 How It Works

  • A control chart helps one record data and lets you see when an unusual event, such as a very high or low observation compared with “typical” process performance, occurs.

  • Control charts attempt to distinguish between two types of process variation:

    • Common cause variation, which is intrinsic to the process and will always be present
    • Special cause variation, which stems from external sources and indicates that the process is out of statistical control
    • Various tests can help determine when an out-of-control event has occurred.

3.1.3 SPC focus on 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.

3.2 HOW CUSUM CHARTS WORK

3.2.1 simple performance barchart

3.2.2 simple performance barchart plus Target line

3.2.3 performance barchart plus cumulative sum of shortfalls

3.2.4 …full effect: barchart plus target plus cumulative sum of shortfalls

3.3 Cause & Effect Analysis: the Fishbone plot

(Using A1c > 9 as example)

3.3.1 SixSigma version

3.3.2 qcc version

3.4 Components of SPC QA

3.4.0.1 Data

  • Type: UDS Medical Measures
  • Period: monthly; October 2020 to date
  • Source: Azara CSVS data
  • Analysis: R / RStudio

3.4.0.2 SPC chart (CUSUM-focused)

  • Org profile
  • Clinic profile
  • Physician Profile

3.4.0.3 Panelling (optional):

  • Clinics, Providers & Measures

3.4.0.4 Ishikawa (“Fishbone”) Plot

  • R packages / version: SixSigma, QCC

3.4.0.5 Personnel

  • Process control & management: QA/QI staff
  • DMAIC cycle (Define, Measure, Analyze, Improve, Control): QA/QI staff
  • Peer Review: QA + Physicians + Clinical Leadership
  • Physician Eval

3.5 DATA

3.5.1 UDS Medical Measures (12):

3.5.1.0.1 target-based (7):
  • 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)
3.5.1.0.2 non-target-based(5):
  • 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)

3.6 Profiles

3.6.1 Org profile by ALL Measures (mean-based)

3.6.2 Org profile target-based Measures

3.6.3 Provider by Measures: Mean-based CUSUM (% Completed Referrals)

3.6.4 Clinic by Measures: Target-Based (% A1c >9)

3.7 SUMMARY

  • Focus on PROCESS control

  • Detect small output deviations (indicating faulty process) using CUSUM charts

  • Use profiles for comparison

  • Analyze & determine cause - effect using FISHBONE diagram.

  • need early warning? Then CUSUMS are your friend

  • Make appropriate changes to the process

  • Monitor with CUSUM charts

3.8 GOAL

  • Improve performance in every measure

  • Generalize the improved performance

  • Apply method to peer review and provider evaluation