Skip to Content
Interactive Textbook on Clinical Symptom Research Logo


Home Button

Learning from Quality Improvement
Author Bio
Introduction
The Challenges of Pragmatic Science
The First Element
Currently selected section: The Second Element
The Third Element
The Fourth Element
Self Test
Conclusion

 


Chapter 13: Learning from Quality Improvement in Healthcare Systems: The Second Element: Determining the Performance of the System Over Time
 
     

Understanding Variation in the Time Series

As most researchers are aware, random or externally-produced variations make it difficult to interpret time series data in the absence of a control, particularly when the aim is to evaluate the effect of a single intervention. Since controls are often not feasible for large system improvement, skilled practitioners of quality improvement use sophisticated analysis of time series to protect against incorrect causal inference. From a quality improvement perspective, the patterns in the data for the measures of system performance provide an opportunity to learn about the system, what affects its performance, and how the cause of the trend might interact with the changes. Understanding variation in the measures of performance is central to the learning process.

The theory for understanding variation in system performance was developed by Shewhart (1986). At times he observed patterns of variation that were of similar magnitude over time and that were free of trends and outlying values, such as these data on admissions for congestive heart failure:

Figure 4.2 Percent Admissions of Patients with Congestive Heart Failure
Graphic depiction of data on admissions for congestive heart failure, described in text.

Source: Chronic II Collaborative, CHRISTUS St. Frances Cabrini Hospital, Alexandria, LA. Reprinted with permission from Suzanne Edwards.

Shewhart concluded that these patterns reflected a system that was stable with respect to the performance measures. He further concluded that the multitude of causes that interacted to produce the variation must be continuously present in the system. He called them "common causes."

Shewhart also observed other patterns that were not so regular. Trends, abrupt shifts of average performance levels, and outlying values inflated the variation. Shewhart concluded that these unpredictable patterns were caused by some specific circumstances--a "special cause" of variation. He hypothesized that a vigilant and frequent observer of the time series, such as a nurse providing pain relief daily to patients, could identify the special cause of variation. He developed a method of informed observation and action that has been called Statistical Process Control (Wheeler, 1995). This method argues that as the team identifies and removes special causes, variation is reduced, the system becomes stable, and the investigator is more reliably able to determine the effect of subsequent changes.

In sophisticated quality improvement, work systems are first stabilized and variation is reduced, usually by instituting changes such as standard protocols or guidelines. Only then are more fundamental changes made in an attempt to raise system performance. This sequence of stabilization, improved performance, and re-stabilization at the new level of performance allows practitioners of quality improvement to make sustainable improvement and provide reliable evidence of the effectiveness of the changes even when controls are not feasible.

In addition to providing the concepts for understanding variation, Shewhart provided the control chart method, an effective way of finding a signal of changed performance from repeated small samples.

Page 17 of 28
Previous Page