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 Valley chose to collect monthly data on the number of infections after surgery. The data collected is shown below.

Month	Surgeries	Infections	Percent		Month	Surgeries	Infections		Percent
1	208	1	0.48		19	187	1		0.53
2	225	3	1.33		20	252	2		0.79
3	201	3	1.49		21	201	1		0.50
4	236	1	0.42		22	226	0		0.00
5	220	3	1.36		23	222	2		0.90
6	244	1	0.41		24	212	2		0.94
7	247	1	0.40		25	219	1		0.46
8	245	1	0.41		26	223	2		0.90
9	250	1	0.40		27	191	1		0.52
10	227	0	0.00		28	222	0		0.00
11	234	2	0.85		29	231	3		1.30
12	227	4	1.76		30	239	1		0.42
13	213	2	0.94		31	217	2		0.92
14	212	1	0.47		32	241	1		0.41
15	193	2	1.04		33	220	3		1.36
16	182	0	0.00		34	278	1		0.36
17	240	1	0.71		35	255	3		1.18
18	230	1	0.43		36	225	1		0.44
Totals						8095

1. Using the data above, what is the average percentage of infections?
2. Construct (and submit) a Run Chart. What conclusions do you reach? What questions does it raise for you?
3. Calculate the UCL and LCL for this data set.
4. Construct and submit a Control Chart. Is the process stable (common cause variation)? Explain.
5. What actions, if any, should management take? Consider only the data, run chart, and control chart.
6. Explain what factors you would consider in selecting an appropriate threshold and why you would consider those factors.
7. 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?
8. Suppose you are told that the same survey disclosed a wide variation in infection rates. Some hospitals reported surgical infection rates as high as 8% while others consistently reported rates as low as 0.4%. What threshold would you recommend Sandy Creek establish? What actions, if any, should management take?