The Joint Commission monitors and evaluates health care providers according to strict standards and guidelines. Improvement in the quality of care is a principal concern. Hospitals are required to identify and monitor important quality indicators that affect patient care and establish "thresholds for evaluation" (TFEs), which are levels at which special investigation of problems should occur. TFEs provide a means of focusing attention on nonrandom errors (that is, special causes of variation). A logical way to set TFEs is through control charts.

Kirkland Hospital collects monthly data on the number of infections after surgeries. The data is shown below. Hospital administrators are concerned about whether the high percentages of infections are caused by factors other than randomness.

Month	Infections	Surgeries		Month	Infections	Surgeries
1	1	208		19	1	187
2	3	225		20	2	252
3	3	201		21	1	201
4	1	236		22	0	226
5	3	220		23	2	222
6	1	244		24	2	212
7	1	247		25	1	219
8	1	245		26	2	223
9	1	250		27	1	191
10	0	227		28	3	222
11	2	234		29	6	231
12	4	227		30	4	239
13	2	213		31	4	217
14	1	212		32	5	241
15	2	193		33	6	220
16	0	182		34	5	278
17	1	240		35	7	255
18	1	230		36	4	225

Using the Excel template provided, do the following:

1. Determine the average percentage of infections.2. Construct appropriate control charts, compute the upper and lower control limits, plot the data, and determine if the process is in statistical control. Based on your analysis, what action, if any, should the hospital administrators take?3. What TFE should management use to monitor future data?