*TS: – Reading A Control Chart – Guidance For Users (PDF/QV) [REF: NRI, PI] Technical Notes, March 10, 2016, Pg 3 published by the Behavioral Healthcare Performance Measurement System of the National Association of State Mental Health Program Directors Research Institute, Inc. (NRI) NRi1603_B5

     Control Charts are the first glimpse of the facility processes related to a measure. A control chart uses only facility data and displays the monthly performance rates with upper and lower control limits. When a control chart is stable, the monthly data points will fluctuate around the center line in a random pattern.

     There are three common rules used by The Joint Commission to indicate that a process is not stable:

1. Any monthly data point outside the control limits

2. A series of 6 consecutive points increasing or decreasing

3. A series of 8 consecutive points on the same side of the center line

     If any of the above rules are violated, the facility should begin an investigation into the cause of the change. A root cause analysis is typically performed by the facility. NRI can offer its services* to assist in this investigation. A quality committee may be a good resource for understanding and reacting to changes in the processes.

     An active quality or process improvement initiative should result in a chart displaying an unstable process (rule 2 or 3) – this is the intended result of the initiative!

     Tip: NRI suggests that the facility mark-up their control charts with their investigation notes so that the materials are available to the facility when The Joint Commission arrives for a triennial review. Remember that The Joint Commission data will be older than the live facility reports available through NRI, so it is beneficial to keep historical records when the processes were considered not stable.

     See also: Comments section of this article for more info on NRI Services and RCA resources