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Problem
Sandy Creek Hospital is owned by Community Hospitals, Inc. (CHI), a large conglomerate of small and mid-sized hospitals across the U.S. CHI requires every hospital to identify and monitor important quality indicators, also sometimes called key performance indicators (KPIs), that affect patient care and to establish thresholds that should be met for each KPI. Sandy Creek chose to collect monthly data on the number of infections after surgery. The data collected is shown in the attachment, Table 1 - Number of Infections After Surgery.
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Hospital administrators are concerned about whether the high percentages of infections (such as 1.76 % in month 12) are caused by factors other than randomness. They are also concerned about what threshold they should establish for this key performance indicator (KPI).
Suppose you are told a recent survey disclosed that of 30 million surgical procedures performed in the U.S. last year, nearly 500,000 (1.7%) resulted in infections. What threshold would you recommend Sandy Creek establish? What actions, if any should management take?
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