A performanceimprovement specialist at an ambulatory surgery center is facilitating a Plan-Do-Study-Act Cycle (PDSA) process...

When discussing the aggregate results of the PDSA cycle to improve hand hygiene compliance, it is crucial to highlight the contributing factors to the variation in results over the past 12 months. The data shows fluctuations in compliance rates, with a peak in Q3 and declines in Q2 and Q4. Analyzing and understanding the reasons behind these variations is essential for identifying what worked well and what challenges arose. This approach allows the Quality Committee to develop strategies to address the inconsistencies and sustain improvements.

Lack of overall change (A): This statement is inaccurate as there were periods of significant improvement, especially in Q1 and Q3.

Sharp and consistent decline (C): This is misleading, as the data does not show a consistent decline; rather, it shows fluctuations.

Overall improvement (D): While there was some improvement, the focus should be on understanding the causes of the variability rather than just the overall trend.

References

NAHQ Body of Knowledge: Performance and Process Improvement

NAHQ CPHQ Exam Preparation Materials: PDSA Cycle and Data Analysis

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