Case Questions for Discussion: 1. Using the data in Exhibit 17.8, what is the average percentage of infections? 2. Construct an appropriate control chart, compute the upper and lower control limits, plot the data on the chart, and determine if the process is in statistical control. Based on your analysis, what action, if any, should management take? 3. What threshold for evaluation should management use to monitor future samples as a basis for taking action? The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 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 a 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. Eckhardt Hospital collected data on the number of infections that occurred for samples of 200 surgeries each month over a three-year period. These data are shown in Exhibit 17.8 and are available in the worksheet Eckhardt Hospital Case Data in MindTap. Hospital administrators are concerned about whether a high number of infections (such as in month 12) are caused by factors other than randomness. xhibit 17.8 Monthly Data on Number of Infections Month Number of Infections Per 200 Surgeries AWN 8 3 5 3 1 b 7 S 9 10 1 2 4 12 13 14 15 16 17 18 2 1 2 0 1 20 21 22 23 24 2 2 27 WE QE ONE 30 31 32 33 34 35 36