MONITORING PATIENTS USING CONTROL CHARTS: A SYSTEMATIC REVIEW

1. MONITORING PATIENTS USING CONTROL CHARTS: A SYSTEMATIC REVIEW JONATHAN ATZMON HARISON BAKER CARSON BEST JONATHAN EASTER Tennant, R., M. A. Mohammed, J. J. Coleman, and U. Martin. "Monitoring Patients Using Control Charts: A Systematic Review." International Journal for Quality in Health Care 19.4 (2007): 187-94. Oxford University Press. Web. 5 Feb. 2015. <http://intqhc.oxfordjournals.org/content/19/4/187>. Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

2. Introduction • Objectives: To systematically review the uses control charts have to monitor clinical variables in individual patients • The Control charts looked at four conditions: hypertension, asthma, renal function post-transplant and diabetes • The studies fell into two categories • Three studies compared control charts to already existing “golden standard methods” • Four studies looked at outcomes of using control charts on individual patient-care Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

3. Introduction (Continued) • Process control charts were invented by Shewhart for controlling manufacturing processes • Control charts are now being used to monitor chronic diseases • Control charts distinguish between two separate sources of variation: common cause and special cause • Common cause variation is intrinsic to any process and is reduced by fundamentally changing the underlying process • Special cause variation is caused by a factor extrinsic to the process and is reduced by the extrinsic factor being found and then acted upon Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

4. Methods • Keywords: control charts, statistical process control (SPC), and other medical subject heading (MeSH) terms • Selection of Studies • Application of control charts to monitor variation in individual patient care • NO restrictions on language or year of publication • 2 reviewers independently reviewed and scored the articles based on inclusion criteria • Data Analysis: Data was collected from the accepted articles, and organized in a modified data extraction sheet Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

5. Variation in the Monitoring and Treatment of Patients Common Cause Special Cause Scheduling of services Scheduling of treatments Working hours of staff Shift change SOPs The order in which patients are seen and treated Priority rules and acuity scales • Differences in symptoms • Differences in diseases • The time of day the patient arrives • The time of day the patient is treated • The socio-economic differences amongst patients • Staff skills • Motivation Variation - An Overview. (n.d.). Retrieved February 5, 2015, from http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/variation_-_an_overview.html Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

6. Interpretation of Control Charts (Figure 1) • Test 1: An extreme point beyond the control limits • Test 2: (2 or 3) out of 3 points in zone A or beyond • Test 3: (4 or 5) out of 5 points in zone B or beyond • Test 4: Run of 8 or more points above or below the centerline (CL) • Test 5: 6 or more points continuing to increase or decrease • Test 6: 14 or more points oscillating up and down • Test 7: 8 in a row on either side of the CL NOT in zone C • Test 8: 15 in a row on either side of the CL in zone C only Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

7. Results • 7 Abstracts Included in Review • 4 – Asthma • 2 – Hypertension • 1 – Kidney Transplant • Differences in: • Number of Patients in the Study • Type of Control Chart • Variables Modeled in Control Charts • Goals of Studies Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

8. Results (Continued) • Changes to Treatment Regime Brought Statistical Control to Control Charts: • 2 showed change as it was happening • 2 showed change with before and after charts • In Comparison to Published Guidelines: • 2 found that control charts were more accurate • 1 found that control charts were less accurate • Number of Rules used to Detect Special Causes of Variation: • 3 used a single exceedence of three-sigma • 2 used more than one rule • Patient and Carer Experience • 3 asserted that control charts enhanced the experience of both patients and carers Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

9. Control charts are promising but are still largely under researched for use of examining medical clinical variables and individual patients. (2007) • Control charts are promising but are still largely under researched for use of examining medical clinical variables and individual patients. (2007) • Comparison of control chart standards vs “gold Standard methods” • examine sensitivity and specificity Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

10. Using control charts to monitor clinical variables leads to internal issues. • Using control charts to monitor clinical variables leads to internal issues. • what variable is monitored? • How frequent? • Who monitors? • Which type of chart is to be used? Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

11. The type of control chart used varies depending on data type. • CUSUM charts vsshewhart • CUSUM charts for individual patients • Shewhart for data with larger parameters • 3 sigma, 1-370 points out side of normal distribubtion Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner

12. “The ultimate purpose for data is to provide a basis for action” • Questions? Atzmon, Baker, Best, Easter ISE 468/ETM 568, Healthcare Process Improvement, Spring 2015, Dr. Joan Burtner