Run Chart

Definition: A Run Chart shows the manner in which a measurement varies over time.
The annotations show PDSAs tested (interventions) or explanations for changes in the data ie: shifts, trends and astronomical data points.
A graph will automatically build as you enter your information into the tables below (follow steps below)

Steps to follow to build your Run Chart:

Step 1: Click on SAVE AS and down load this spread sheet onto your computer. Rename the file.
Step 2: X-axis: Enter your time series categories into the table below (in chronological order) eg: either month, week, day, Patient 1,2,3 or date of audit or observation number etc...
Step 3: Enter the numbers # for the Continuous Data Run chart or the numerator and denominator for the Attribute Data Run chart and the rate will calculate automatically (the m
Step 4: Key your stretch goal into the first cell of the Stretch goal column (coloured yellow). Your stretch goal is your aspirational target.
Step 5: Delete unused row/s (from the bottom up) by highlighting the row/s (from outside the sheet in the row # column) then right clicking and click on 'delete'.
Step 6: Type information into the Annotation boxes from the PDSA column (delete unwanted annotation boxes). Point arrow to the time that the PDSA occurred. To add more anno
Step 7: Enter the Title of your graph: Click on the graph, click on the title, then enter the information you want displayed eg: Title and operational definition of numerator and denom
Step 8: To print graph: Click on graph to highlight it, then click on print button. Or use the 'Snipping" tool to snip and paste an image of your graph into another document ie: MS 'P
See Run Chart Examples on next Sheet (tabs)
Template developed by Wendy Jamieson - April, 2001. Revised January 2017, May 2018, March, 2019, Aug 2020.

Run Chart for Percentage (%) / Proportion ie: Classification data (Attribute data)

Do not alter this Do not alter this OPTIONAL:

column column Key your stretch goal
(it calculates (it calculates into the first cell
automatically) automatically) (coloured yellow)
 X-axis
Date or Observation in Numerator Denominator
CHRONOLOGICAL ORDER eg: (top number in the (bottom number in Percent % Median Stretch Goal
month, week, day, Patient 1,2,3 fraction) the fraction)
or date of audit etc...

#DIV/0! #DIV/0!
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
#DIV/0! #DIV/0! 0.0%
 #DIV/0! #DIV/0! 0.0%
Statistical Process Control SPCC: SPCC:
Chart (SPCC): Use this column of data Use this column of data
Use this column of data to to produce a to produce a
produce a P Chart P Chart
P Chart

Run Chart for COUNT data (Attribute (discrete) data)

X-axis
Date or Observation in Change ideas tested via
CHRONOLOGICAL ORDER eg: Count of incident Median Stretch Goal PDSA
month, week, day, Patient 1,2,3
or date of audit etc...

#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
 #VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
#VALUE! 5
SPCC: SPCC:
Use this column of data to Use this column of data
produce a to produce a
C Chart C Chart
Run Chart for COUNT data for a RATE (Attribute (discrete) data)

Incident Rate per 1000 Occupied Bed Days. Calculation: # incidents / (Occupied Bed Days/1000)

Do not alter this Do not alter this

Do not alter this column column
column. (it calculates automatically) (it calculates automatically)

X-axis Occupied Bed Days (or

Date or Observation # eg: # incidents Line Days, Separations 1000 OBD/1000 Rate per 1000 Occupied
month, week, day or date of etc) Bed Days
audit etc...

1000 0.00 #DIV/0!

1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
 1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
1000 0.00 #DIV/0!
SPCC: SPCC: SPCC:
Use this column to produce a Use this column to Use this column to
U Chart produce a produce a
U Chart U Chart

Run chart for Continuous (Variable) data

 Y-Axis to be a
MEASURE ie: time OPTIONAL: Key your
Do not alter this stretch goal into the
(mins, hours), height, column first cell (coloured
weight, volume, # of (it calculates automatically)
yellow)
surgeries, $ etc.

X-axis
Date or Observation # eg: Change ideas tested via
month, week, day or date Measure: Median Stretch Goal PDSA
of audit etc...

#VALUE!
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
 #VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
#VALUE! 0
SPCC: SPCC:
Use this column of data to Use this column of data to
produce a produce a
I Chart (Measure) I Chart (Measure)

X Bar & S Chart Template

 Continuous data - MEASURE per individual, case or unit ie: time (mins, hours), turn-around time, wait time for treatment (hours or w

X-axis Case 1 Case 2 Case 3 Case 4 Case 5

Time period Measure Measure Measure Measure Measure
 SPCC: SPCC: SPCC: SPCC: SPCC: SPCC:
Use this column of data to Use this column of data Use this column of data Use this column of data Use this column of data Use this column of data
produce a to produce a to produce a to produce a to produce a to produce a
X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart

Time Between Chart - Time (Days/Weeks) between incidents

MANUAL CALCULATION
required to determine
the time between
incidents

Number of Days between Change ideas tested via

Date of Incident Incidents Median PDSA

#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
 #VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
#VALUE!
SPCC: SPCC:
Use this column of data to Use this column of data
produce a to produce a
T Chart T Chart
r observation number etc...
culate automatically (the median will also automatically calculate).

ccurred. To add more annotation boxes & arrows - 1) Click on Graph; 2) via INSERT menu: Click on Graph, INSERT menu, Text Box, drop & drag, type in words. Insert arrow via INSERT shapes and s
on of numerator and denominator.
nother document ie: MS 'Power Point' or 'Word".
 Title ...
Change ideas tested
Run Chart
via PDSA Operational Definition: Numerator: ... Denominator: ...
Percent % Median Stretch Goal

PDSA ... PDSA ... PDSA ... PDSA ...

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
 10%

0%

Title of Chart ...

Run Chart
Definition of a fall: An event which results in a person coming
Count of incident Median to restStretch
inadvertently
Goal on the ground or floor
PDSA
other lower level.
PDSA PDSA P

4
Count

2
 4

Count
3

0
d Days/1000)

Place your stretch goal Do not alter this

figure in the yellow column
cell. (it calculates automatically)

Change ideas tested via Rate per 1000

Stretch Goal Median
PDSA
1

#DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0! PDSA 1 ...
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0! 1
0 #DIV/0!
 1

0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0!
0 #DIV/0! 0
0 #DIV/0!
0 #DIV/0!
 Title....
Run Chart

Measure: Measure: Median Stretch

1
PDSA PDSA
PDSA ...

1
1

0
 Do not alter this
column
or treatment (hours or weeks), height, weight, $ etc. (it calculates automatically)

Case 6 Case 7 Case 8 Case 9 Case 10

Y-Axis Average
Measure Measure Measure Measure Measure
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
 SPCC: SPCC: SPCC: SPCC: SPCC:
Use this column of data Use this column of data Use this column of data Use this column of data Use this column of data
to produce a to produce a to produce a to produce a to produce a
X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart

? Days? between ........ Incidents

(Desired direction of chart / data is up)
Number of Days between Incidents Median

PDSA 1 ... PDSA 2 ... PDSA 3 ... PDSA 4 ...

12

10
between incidents

6
 10

? Days? between incidents

8

Date Incident Occurred

ert arrow via INSERT shapes and select an arrow, drop in graph and drag.
Denominator: ...
Stretch Goal

PDSA ... PDSA ...

on the ground or floor or
A PDSA
 Rate per 1000 ...
Run Chart
Calculation: Calculation: # incidents / (Occupied Bed Days/1000)
Operational definition: ...
Rate per 1000 Occupied Bed Days Stretch Goal Median

PDSA 3 ... PDSA 4 ... PDSA 5 ...

PDSA 1 ... PDSA 2 ...
tle....
Chart

dian Stretch Goal

PDSA PDSA PDSA ...

Do not alter this
column
(it calculates
automatically) T

Median Change ideas tested via

Y-Axis Av
PDSA
1
#DIV/0!
#DIV/0!
#DIV/0! PDSA 1 ... P
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
Axis Title

#DIV/0!
1
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!

0
 0

.. Incidents
t / data is up)
dents Median

PDSA 4 ... PDSA 5 ...

t Occurred
1000)
Median

PDSA 5 ...
 Title: xxxxxxxx
Run Chart
Y-Axis Average Median

DSA 1 ... PDSA 2 ... PDSA 3 ... PDSA 4 ... PDSA 5...
Run Chart Examples
Example data only

SEPSIS - Observation & Frequency with Median, Average & Stretch Goal.

Do not alter this column.

It calculates
Do not alter this
column. It calculates
Key your stretch
goal into the first P
automatically automatically cell (coloured
yellow)
Centre Line NOT
Phased
Minutes
300
X-axis Change
Date or Observation # e.g.: Centre Line Average Stretch Goal <60 concepts
month, week, day or date of
Minutes Median (Mean) minutes Median
tested via
audit etc...
PDSA
250

Patient 1 143 110 94 60 80

Patient 2 75 110 94 60 80
Patient 3 134 110 94 60 80
200
Patient 4 146 110 94 60 80
Patient 5 157 110 94 60 80
Patient 6 163 110 94 60 80
Patient 7 172 110 94 60 80
60
150
Patient 8 184 110 94 80
Patient 9 126 110 94 60 80

100
 150

Patient 10 66 110 94 60 80
Patient 11 125 110 94 60 80
110 94 60 80
100
Patient 12 79
Patient 13 258 110 94 60 80
Patient 14 89 110 94 60 80
Patient 15 112 110 94 60 80
Patient 16 159 110 94 60 80 50
Stretch Goal 60 m
Patient 17 76 110 94 60 80
Patient 18 123 110 94 60 80
Patient 19 99 110 94 60 80
Patient 20 105 110 94 60 80 0
110 94 60 80 1 2 3 4 5 6 7 8
Patient 21 278
ent ent ent ent ent ent ent ent
60 ti ti ti ti ti ti ti ti ti
Patient 22 67 110 94 80 Pa Pa Pa Pa Pa Pa Pa Pa Pa
Patient 23 87 110 94 60 80
Patient 24 67 110 94 60 80
Patient 25 97 110 94 60 80
Patient 26 63 110 94 60 80 Phasing of Median line (see graph
Patient 27 87 110 94 60 80 ON the table to th
Patient 28 98 110 94 60 80
Patient 29 69 110 94 60 80
Patient 30 110 110 94 60 80 Sepsi
Patient 31 199 110 94 60 80
Patient 32 64 57 94 60 80
Patient 33 83 57 94 60 80
Patient 34 52 57 94 60 80 Minutes
Patient 35 57 57 94 60 80 300
Patient 36 86 57 94 60 80
Patient 37 67 57 94 60 80
Patient 38 65 57 94 60 80
Patient 39 69 57 94 60 80
Patient 40 89 57 94 60 80 250
Patient 41 82 57 94 60 80

200
 250

Patient 42 89 57 94 60 80
Patient 43 80 57 94 60 80
Patient 44 83 57 94 60 80
60
200
Patient 45 56 57 94 80
Patient 46 64 57 94 60 80
Patient 47 75 57 94 60 80
Patient 48 57 57 94 60 80
Patient 49 48 57 94 60 80
150
Patient 50 52 57 94 60 80
Patient 51 61 57 94 60 80
Patient 52 45 57 94 60 80
Patient 53 55 57 94 60 80
Patient 54 54 57 94 60 80 100
Patient 55 53 57 94 60 80
Patient 56 51 57 94 60 80
Patient 57 49 57 94 60 80
Patient 58 47 57 94 60 80
Stretch Goal
Patient 59 44 57 94 60 80 50
Patient 60 42 57 94 60 80
Statistical Process SPCC:
Control Chart (SPCC): Use this column to
Use this column to produce a
produce a I Chart
I Chart 0
1 2 3 4 5 6
ent ent ent ent ent ent e
ti ti ti ti ti ti ti
Pa Pa Pa Pa Pa Pa Pa
Infections - Annotated Run Chart with Rate, Median line and Stretch
The MEDIAN is a measure of central tendency (what usually happens).
The median is calculated by sorting all the figures from lowest to highest (the median is the figure in the middle). The spread sheet below automatically calculates the median for you
The median is useful when you have an outlier/s (astronomical data point/s) in your data set.
Steps to follow to build your Run Chart:
1. Follow the steps for a Run Chart (see top of spread sheet)
2. Place the Stretch Goal figure in the first row in the Stretch Goal Column (yellow cell) and the other cells in that column will populate (a Stretch Goal is an aspirational target).
3. Delete unused rows and the median will then automatically calculate and median line will appear on the graph.

Key your stretch

Do not alter this Do not alter this goal into the first
column. It calculates column. It calculates
automatically automatically cell (coloured
yellow)

X-axis Denominator Change Ideas

Date or Observation # e.g.: Numerator Rate % Median Stretch Goal
month, week, day or date of (top number in the fraction) (bottom number in the tested via
fraction) PDSA
audit etc...

Jan-18 4 87 4.6% 6.4% 2%

Feb-18 5 78 6.4% 6.4% 2%
Mar-18 6 87 6.9% 6.4% 2%
Apr-18 7 89 7.9% 6.4% 2%
May-18 6 87 6.9% 6.4% 2% 12%
Jun-18 5 76 6.6% 6.4% 2%
Jul-18 4 78 5.1% 6.4% 2%
Aug-18 5 87 5.7% 6.4% 2%
10%
Sep-18 6 89 6.7% 6.4% 2%
Oct-18 7 87 8.0% 6.4% 2%
Nov-18 8 89 9.0% 6.4% 2% PDSA
Dec-18 7 87 8.0% 6.4% 2% 8%
Jan-19 6 89 6.7% 6.4% 2%

6%
 10%

8%

Feb-19 5 90 5.6% 6.4% 2%

Mar-19 4 87 4.6% 6.4% 2%
6%
Apr-19 5 78 6.4% 6.4% 2%
May-19 4 87 4.6% 6.4% 2%
Jun-19 5 87 5.7% 6.4% 2%
Jul-19 7 89 7.9% 6.4% 2% 4%
Aug-19 8 89 9.0% 6.4% 2%
Sep-19 9 87 10.3% 6.4% 2% PDSA
Oct-19 5 87 5.7% 6.4% 2%
2% 2%
Nov-19 4 67 6.0% 6.4%
Dec-19 4 89 4.5% 6.4% 2%
Jan-20 4 87 4.6% 6.4% 2%
Applied Applied Applied 0%
Measurement: Measurement: Measurement:
Use this column to Use this column to Use this column to 18 18 r-1
8
r-1
n- b- a
produce a produce a produce a Ja Fe M Ap
P Chart P Chart P Chart
Infections - Annotated Run Chart with Rate, AVERAGE (Mean) line a
The AVERAGE (also called Mean) is another measure of central tendency (what usually happens).
The spread sheet below automatically calculates the AVERGE for you.

Steps to follow to build your Run Chart:

1. Follow the steps for a Run Chart (see above)
2. Place the Stretch Goal figure in the first row in the Stretch Goal Column (yellow cell) and the other cells in that column will populate (a Stretch Goal is an aspirational target).
3. Delete unused rows and the AVERAGE will then automatically calculate and average line will appear on the graph.
NB: The average (mean) should NOT be used if you have an outlier (astronomical data point) in your data set.

Key your stretch

Do not alter this Do not alter this goal into the first
column. It calculates column. It calculates
automatically automatically cell (coloured
yellow)

X-axis Denominator Change Ideas

Date or Observation # e.g.: Numerator Average (centre
month, week, day or date of (top number in the fraction)
(bottom number in the Rate % line) Stretch Goal tested via
audit etc... fraction) PDSA
4% 12%

Jan-18 4 87 4.6% 6.5%

4%

10%
Feb-18 5 78 6.4% 6.5%
Mar-18 6 87 6.9% 6.5% 4%
Apr-18 7 89 7.9% 6.5% 4%
May-18 6 87 6.9% 6.5% 4% 8%
Jun-18 5 76 6.6% 6.5% 4%
Jul-18 4 78 5.1% 6.5% 4%
Aug-18 5 87 5.7% 6.5% 4%
4% 6%

Percent
Sep-18 6 89 6.7% 6.5%

4%
 8%

6%

Percent
Oct-18 7 87 8.0% 6.5% 4%
Nov-18 8 89 9.0% 6.5% 4%
Dec-18 7 87 8.0% 6.5% 4%
4% 4%
Jan-19 6 89 6.7% 6.5%
Feb-19 5 90 5.6% 6.5% 4%
Mar-19 4 87 4.6% 6.5% 4%
Apr-19 5 78 6.4% 6.5% 4%
2%
May-19 4 87 4.6% 6.5% 4%
Jun-19 5 87 5.7% 6.5% 4%
Jul-19 7 89 7.9% 6.5% 4%
Aug-19 8 89 9.0% 6.5% 4% 0%
Sep-19 9 87 10.3% 6.5% 4%

Feb-18
Jan-18
Oct-19 5 87 5.7% 6.5% 4%
Nov-19 4 67 6.0% 6.5% 4%
Dec-19 4 89 4.5% 6.5% 4%
Jan-20 4 87 4.6% 6.5% 4%
Applied Applied Applied
Measurement: Measurement: Measurement:
Use this column to Use this column to Use this column to
produce a produce a produce a
P Chart P Chart P Chart
 Place your
stretch goal
figure in the
yellow cell.

Do not alter
Do not alter Do not alter the rest of this Do not alter
this column (it this column (it column (it this column (it
Do not alter calculates calculates calculates calculates
this column. automatically) automatically) automatically). automatically)

Patient Fall Rate per 1000 Occupied Bed Days (Attribute Data). Calculation: # incidents / (Occupie

X-axis Rate per 1000

Date or Observation # e.g.: # incidents Occupied Bed Days 1000 OBD/1000 Occupied Bed Stretch Goal Median
month, week, day or date of
audit etc... Days

Jan-18 6 612 1000 0.61 9.8 4 6.8

Feb-18 5 719 1000 0.72 7.0 4 6.8
Mar-18 7 655 1000 0.66 10.7 4 6.8
Apr-18 3 497 1000 0.50 6.0 4 6.8
May-18 4 553 1000 0.55 7.2 4 6.8
Jun-18 6 649 1000 0.65 9.2 4 6.8
Jul-18 2 502 1000 0.50 4.0 4 6.8
Aug-18 5 514 1000 0.51 9.7 4 6.8
Sep-18 4 507 1000 0.51 7.9 4 6.8
Oct-18 2 443 1000 0.44 4.5 4 6.8
Nov-18 4 516 1000 0.52 7.8 4 6.8
Dec-18 6 587 1000 0.59 10.2 4 6.8
Jan-19 3 612 1000 0.61 4.9 4 6.8
Feb-19 2 604 1000 0.60 3.3 4 6.8
Mar-19 5 597 1000 0.60 8.4 4 6.8
Apr-19 7 543 1000 0.54 12.9 4 6.8
May-19 4 491 1000 0.49 8.1 4 6.8
Jun-19 4 498 1000 0.50 8.0 4 6.8
Jul-19 3 507 1000 0.51 5.9 4 6.8
Aug-19 1 509 1000 0.51 2.0 4 6.8
Sep-19 4 512 1000 0.51 7.8 4 6.8
Oct-19 4 642 1000 0.64 6.2 4 6.8
Nov-19 4 605 1000 0.61 6.6 4 6.8
Dec-19 6 581 1000 0.58 10.3 4 6.8
Jan-20 3 556 1000 0.56 5.4 4 6.8
Feb-20 4 657 1000 0.66 6.1 4 6.8
Mar-20 3 689 1000 0.69 4.4 4 6.8
Apr-20 1 578 1000 0.58 1.7 4 6.8
May-20 3 603 1000 0.60 5.0 4 6.8
Jun-20 2 615 1000 0.62 3.3 4 6.8
Applied Applied Applied
Measurement: Measurement: Measurement:
Use this column to Use this column to Use this column
produce a produce a to produce a
U Chart U Chart U Chart

Random vs. Non-Random variation

Turn around time of blood test results (minutes)
Patients in Turn around time of
Chronological Order test (Minutes) Median

Patient 1 35 35 Turn Around Time of Blood Test R

Patient 2 42 35 Run Chart
Patient 3 43 35
Patient 4 29 35 Turn around time of test (
Patient 5 42 35 100
Patient 6 40 35
Patient 7 35 35 90
Patient 8 31 35
Patient 9 48 35 80
Patient 10 35 35
Patient 11 25 35 70
Patient 12 37 35

Minutes
Patient 13 48 35 60
Patient 14 35 35
Patient 15 41 35 50
Patient 16 32 35
Patient 17 38 35 40
Patient 18 40 35
Patient 19 28 35 30
Patient 20 46 35
Patient 21 40 35 20
Patient 22 21 35
Patient 23 31 35 10
Patient 24 40 35
Patient 25 16 35 0
Patient 26 28 35
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8
Patient 9
Patient 10
Patient 11
Patient 12
Patient 13
Patient 14
Patient 15
Patient 16
Patient 17
Patient 18
Patient 19
Patient 20
Patient 21
Patient 22
Patient 23
Patient 24
Patient 25
Patient 26
Patient 27
Patient 28
Patient 27 28 35
Patient 28 17 35

Patients in chronologic
 0

Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8
Patient 9
Patient 10
Patient 11
Patient 12
Patient 13
Patient 14
Patient 15
Patient 16
Patient 17
Patient 18
Patient 19
Patient 20
Patient 21
Patient 22
Patient 23
Patient 24
Patient 25
Patient 26
Patient 27
Patient 28
Patient 29 28 35
Patients in chronologic
Patient 30 26 35
Patient 31 15 35
Patient 32 48 35
Patient 33 39 35
Patient 34 42 35
Patient 35 39 35
Patient 36 37 35
Patient 37 39 35
Patient 38 47 35
Patient 39 27 35
Patient 40 32 35
Patient 41 94 35
Patient 42 14 35
Patient 43 17 35
Patient 44 20 35
Patient 45 32 35
Patient 46 41 35
Patient 47 45 35
Patient 48 22 35
Patient 49 39 35
Patient 50 33 35
Patient 51 25 35
Patient 52 23 35
Patient 53 18 35
Applied Applied
Measurement: Measurement:
Use this column to Use this column to
produce a produce a
I Chart I Chart
What is a run in a run chart
Turn around time of blood test results (minutes)
Patients in Turn around time of
Chronological Order test (Minutes) Median

Patient 1 35 40 Day time 1

Patient 2 42 40 Day time 2
Patient 3 43 40 Day time 3
Patient 4 49 40 Day time 4 Blood Test Turn
Patient 5 42 40 Day time 5 R
Patient 6 40 40 Day time 6
Patient 7 32 40 Day time 7 Turn around time
Patient 8 45 40 Day time 8
Patient 9 48 40 Day time 9 60

Patient 10 35 40 Day time 10

Patient 11 32 40 Day time 11 50
Patient 12 32 40 Day time 12
Patient 13 48 40 Day time 13
40
Patient 14 45 40 Day time 14
Patient 15 41 40 Day time 15
Patient 16 32 40 Day time 16
Minutes
30

20

10
 40

Minutes
30
Patient 17 38 40 Day time 17
Patient 18 40 40 Day time 18
20
Patient 19 46 40 Day time 19
Patient 20 46 40 Day time 20
Patient 21 40 40 Day time 21 10
Patient 22 35 40 Day time 22
Patient 23 31 40 Day time 23
0
Patient 24 40 40 Day time 24
1 2 3 4 5 6 7 8 9 0 1 2 3
Patient 25 49 40 Day time 25 nt nt nt nt nt nt nt nt nt t1 t1 t1 t1
atie atie atie atie atie atie atie atie atie tien tien tien tien tien
P P P P P P P P P Pa Pa Pa Pa Pa
Patient 26 35 40 Day time 26
Patient 27 32 40 Day time 27 Patien
Patient 28 31 40 Day time 28
Patient 29 28 40 Day time 29
Patient 30 26 40 Day time 30
Applied Applied
Measurement: Measurement:
Use this column to Use this column to
produce a produce a
I Chart I Chart

Too Many and Too Few Runs

Too few
Turn around time of blood test results (minutes) runs
 Patients in Turn around time of Turn around
Chronological Order test (Minutes) Median Stratification time of test Median
(Minutes)

Patient 1 35 64 Day time 1 75 60.00

Patient 2 82 64 After hours 2 81 60.00 100
Patient 3 39 64 Day time 3 82 60.00
Patient 4 86 64 After hours 4 74 60.00 90
Patient 5 42 64 Day time 5 78 60.00
Patient 6 89 64 After hours 6 73 60.00
79 80
Patient 7 41 64 Day time 7 60.00
Patient 8 79 64 After hours 8 82 60.00
Patient 9 35 64 Day time 9 81 60.00 70
Patient 10 80 64 After hours 10 73 60.00
Patient 11 32 64 Day time 11 73 60.00 60
Patient 12 87 64 After hours 12 79 60.00
77

Minutes
Patient 13 37 64 Day time 13 60.00 50
Patient 14 84 64 After hours 14 69 60.00
Patient 15 41 64 Day time 15 78 60.00
43 40
Patient 16 81 64 After hours 16 60.00
Patient 17 38 64 Day time 17 45 60.00
Patient 18 89 64 After hours 18 43 60.00 30
Patient 19 46 64 Day time 19 49 60.00
Patient 20 90 64 After hours 20 51 60.00 20
Patient 21 39 64 Day time 21 42 60.00
Patient 22 86 64 After hours 22 39 60.00 10
Patient 23 40 64 Day time 23 46 60.00
Patient 24 82 64 After hours 24 41 60.00
25 0
Patient 25 49 64 Day time 25 60.00
t1 t2 t3
Patient 26 91 64 After hours 26 31 60.00 ti en ti en ti en tie
Pa Pa Pa Pa
Patient 27 32 64 Day time 27 26 60.00
Patient 28 88 64 After hours 28 23 60.00
Patient 29 36 64 Day time 29 19 60.00
Patient 30 84 64 After hours 30 13 60.00
Statistical Process SPCC:
Control Chart (SPCC): Use this column to
Use this column to produce a
produce a I Chart
I Chart

Different run charts for different situations

Run Chart for COUNT data (Attribute (discrete) data)

Number of Incidents of post operative bleed after

Elective Surgery

# post-operative
Stretch Goal =
Month bleed incidents Median
0 Count (number) of In

# post-operative bleed incid

Jan 1 1 0
5
Feb 1 1 0
Mar 1 1 0
Apr 0 1 0 4

Count
May 1 1 0
3

2
 5

Count
Jun 0 1 0 3
Jul 0 1 0
Aug 1 1 0
2
Sep 1 1 0
Oct 2 1 0
1
Nov 3 1 0
Dec 4 1 0
SPCC SPCC: 0
Use this column of Use this column of Jan Feb Mar Apr May
data to produce a data to produce a
C Chart C Chart

Percentage of Venous Thromboembolism (VTE) incidents after Elective Surgery

Month NUMERATOR: DENOMINATOR: % of VTE Median Stretch Goal =
# VTE incidents # elective cases 0% Percentage of Ve
for month operations for a
month

0% 12%
Jan 5 65 8% 5% % of VTE cas
Feb 3 92 3% 5% 0%
Mar 2 56 4% 5% 0% 10%
Apr 5 61 8% 5% 0%
May 6 92 7% 5% 0%
8%
Jun 6 56 11% 5% 0%
Jul 4 99 4% 5% 0%
6%

4%
 10%

8%

Aug 9 109 8% 5% 0% 6%

Sep 7 132 5% 5% 0%
Oct 5 152 3% 5% 0% 4%
Nov 4 161 2% 5% 0%
Dec 2 172 1% 5% 0%
2%
Applied Applied Applied
Measurement: Measurement: Measurement: Stretch goal = 0%
Use this column of Use this column of Use this column of
data to produce a data to produce a data to produce a 0%
P Chart P Chart P Chart Jan Feb Mar Apr M

Percentage of elective surgery patients Screened pre-operatively for Venous Thromboembolism (VTE) risk
Month NUMERATOR: DENOMINATOR: % of patients Median Stretch Goal
# Patients # elective screened
screened pre-op operations for Percentage of elective surge
month Thro

Jan 42 65 65% 81% 100% 100% % of patients s

Feb 74 92 80% 81% 100%
95%
Mar 41 56 73% 81% 100%
Apr 45 61 74% 81% 100% 90%

May 62 92 67% 81% 100% 85%

Jun 45 56 80% 81% 100%
100% 80%
Jul 81 99 82% 81%
Aug 92 109 84% 81% 100% 75%

70%

65%

60%
 90%

85%

80%

75%
Sep 111 132 84% 81% 100%
70%
Oct 142 152 93% 81% 100%
Nov 152 161 94% 81% 100% 65%
Dec 169 172 98% 81% 100%
60%
Applied Applied Applied
Measurement: Measurement: Measurement: 55%
Use this column of Use this column of Use this column of
data to produce a data to produce a data to produce a 50%
P Chart P Chart P Chart Jan Feb Mar Apr M

Percentage of patients at risk of VTE who receive prophylaxis (blood thinning medication)

Month NUMERATOR: DENOMINATOR: % patients at Median Stretch Goal

# Patients given # patients at risk risk of VTE
VTE prophylaxis of VTE who receive Percentage of ele
prophylaxis
medication
100% % patients at risk o

Jan 29 32 91% 88% 100% 95%

Feb 39 45 87% 88% 100%
Mar 20 26 77% 88% 100%
100% 90%
Apr 26 31 84% 88%
May 35 42 83% 88% 100%
Jun 16 21 76% 88% 100% 85%
Jul 50 56 89% 88% 100%

80%

75%
 90%

85%

Aug 42 52 81% 88% 100%

80%
Sep 70 71 99% 88% 100%
Oct 85 85 100% 88% 100%
Nov 72 72 100% 88% 100% 75%
Dec 91 91 100% 88% 100%
Applied Applied Applied
Measurement: Measurement: Measurement: 70%
Use this column of Use this column of Use this column of Jan Feb Mar
data to produce a data to produce a data to produce a
P Chart P Chart P Chart

Surgical Site Infection Rate per 1000 Occupied Bed Days

Month # Infections Occupied Bed Rate of Median
for month Days per Month infections per
for Surgery 1000 OBDs Sur
1000 OBD/1000

8
Jan 5 1648 1000 1.6 3 4
Feb 3 1577 1000 1.6 2 4 7
Mar 2 1794 1000 1.8 1 4

er of Infections per 1000 OBD

Apr 5 1324 1000 1.3 4 4 6
May 6 1323 1000 1.3 5 4
Jun 6 1765 1000 1.8 3 4 5

3
 7

Number of Infections per 1000 OBD

6

5
Jul 4 1019 1000 1.0 4 4
Aug 6 1455 1000 1.5 4 4 4
Sep 7 1180 1000 1.2 6 4
Oct 9 1334 1000 1.3 7 4 3
Nov 7 1825 1000 1.8 4 4
Dec 8 1487 1000 1.5 5 4 2
Applied Applied Applied
Measurement: Measurement: Measurement:
Use this column to Use this column to Use this column 1
produce a produce a to produce a
U Chart U Chart U Chart
0
Jan Feb

Days Between Infection incidents

Number of Days Change ideas
Date of Infection between Infections Median tested via PDSA
Number of days between surgic
3rd Jan 5.5 Run Char
15th Jan 12 5.5 30
Number of Days between Infe
22nd Jan 7 5.5
25th Jan 3 5.5 PDSA 1
30th Jan 5 5.5 25
7th Feb 8 5.5
18th Feb 11 5.5 Days between Infection cases 20
23rd Feb 5 5.5
3rd Mar 8 5.5 PDSA 2
PDSA 2
9th Mar 6 5.5 15
2nd Apr 24 5.5
PDSA 1
13th Apr 11 5.5
18th Apr 5 5.5 10

0
 Days between Infectio
PDSA 2
15

PDSA 1

10
23rd Apr 5 5.5
28th Apr 5 5.5
5
1st May 3 5.5
4th May 3 5.5
8th May 4 5.5 PDSA 3
0
11th May 3 5.5 3rd Jan 15th 22nd 25th 30th 7th Feb 18th 23rd 3rd 9th 2nd
Jan Jan Jan Jan Feb Feb Mar Mar Apr
22nd May 11 5.5
28th May 6 5.5
Applied Applied
Measurement: Measurement:
Use this column of Use this column of
data to produce a data to produce a
T Chart T Chart

Number of Surgical Cases between Surgical site Infection incidents

 Number of surgery Number of Surgical cases be
Date of Infection Change ideas
incident reported
cases between Median tested via PDSA Run Chart
infections
100
Number of surgery cases between infe
90
8th Jan 25 32
19th Jan 32 32 80
24th Jan 21 32
28th Jan 21 32 70

Number of surgical cases

30th Jan 32 32
60
6th Feb 21 32
18th Feb 11 32 50
23rd Feb 25 32
3rd Mar 15 32 40
9th Mar 32 32
30
2nd Apr 15 32
13th Apr 23 32 PDSA 1 20
16th Apr 11 32
10
23rd Apr 34 32
28th Apr 45 32 PDSA 2
0
1st May 54 32 1 2 3 4 5 6 7 8 9 10 11
4th May 57 32 Date of Infectio
8th May 64 32
13th May 72 32
22nd May 63 32
29th May 89 32
 Applied Applied
Measurement: Measurement:
Use this column of Use this column of
data to produce a data to produce a
G Chart G Chart

X Bar & S Chart Template

Wait time (minutes) from labour ward to theatre for an emergency caesarean section

X-axis
Time period Women 1 Women 2 Women 3 Women 4 Women 5 Women 6 Women 7

Week 1 35 15 32 23 25 15 32
Week 2 18 25 32 55 12 19 21
Week 3 18 22 3 25 32
Week 4 16 17 21 32 11 20
Week 5 11 16 13 32 18 7 14
Week 6 21 9 23 21 15 15 13
Week 7 32 12 21 9 2 16
Week 8 12 16 14 13 17 25 19
Week 9 9 8 4 18 12 5 12
Week 10 12 18 21 17 15 16 13
Week 11 10 14 12 13 15 9 8
Week 12 15 12 16 16 13 7 6
Week 13 9 7 4 11 8 7 8
Week 14 7 6 4 6 2 7 8
Week 15 8 7 5 7 1 6 2
Week 16 5 5 6 9 3 9 2
Week 17 4 6 7 3 8 4 5
Week 18 7 7 4 7 4 4 2
Week 19 8 8 5 4 3 4 2
Week 20 3 3 7 5 5 2 2

Statistical Process Control Chart (SPCC):

Use these columns of data to produce a
X Bar & S Chart

Interpretation of a Run Chart: Shift, Trend & Astronomical Data Point

Do not alter this column.

It calculates
automatically
 X-axis
Date or Observation # e.g.: # Median
month, week, day or date of
audit etc...

Patient 1 15 24
Patient 2 31 24
Patient 3 29 24
Patient 4 27 24
Patient 5 15 24
Patient 6 45 24
Patient 7 29 24 #
Patient 8 19 24 100
Patient 9 51 24
Patient 10 35 24
90 SHI
Patient 11 46 24
Patient 12 41 24
>6 points above o
Patient 13 42 24 80
ral l
Values on centre line d
Patient 14 48 24 a sh
Patient 15 19 24
70
Patient 16 21 24
Patient 17 15 24
Patient 18 18 24 60
Patient 19 21 24 Random variation
Patient 20 14 24 50
Patient 21 19 24
Patient 22 94 24
Patient 23 14 24 40
Patient 24 17 24
Patient 25 20 24 30
Patient 26 32 24

20

10
 40

30

Patient 27 45 24
20
Patient 28 35 24
Patient 29 14 24
Patient 30 42 24 10
Patient 31 33 24
Patient 32 25 24
0
Patient 33 23 24
1 2 3 4 5 6 7 8 9 0 1 2
Patient 34 18 24 ent ent ent ent ent ent ent ent ent nt1 nt1 nt1 nt
1
ti ti ti ti ti ti ti ti ti e e e e
Patient 35 13 24 Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa
ti
Pa
ti
Pa
ti
Pa
ti

Patient 36 9 24

Numerator: DENOMINATOR:
Week # Infections # discharges for % of infections Median Stretch Goal
for Week Week
Week 1 5 87 5.7% 3% 1%
Week 2 2 88 2.3% 3% 1%
Week 3 3 91 3.3% 3% 1% 8%
Week 4 5 87 5.7% 3% 1%
Week 5 6 88 6.8% 3% 1%
7%
Week 6 1 80 1.3% 3% 1%
Week 7 2 84 2.4% 3% 1%
Week 8 3 86 3.5% 3% 1% 6%
Week 9 5 87 5.7% 3% 1%
Week 10 2 89 2.2% 3% 1% 5%

4%

Percent
3%
 6%

5%
Week 11 3 92 3.3% 3% 1%
Week 12 5 81 6.2% 3% 1%
4%

Percent
Week 13 3 89 3.4% 3% 1%
Week 14 4 85 4.7% 3% 1%
Week 15 4 80 5.0% 3% 1% 3%
Week 16 5 83 6.0% 3% 1%
Week 17 7 93 7.5% 3% 1% 2%
Week 18 3 79 3.8% 3% 1%
Week 19 2 87 2.3% 3% 1%
Week 20 3 86 3.5% 3% 1% 1%
Week 21 1 89 1.1% 3% 1%
Week 22 2 83 2.4% 3% 1% 0%
Week 23 2 84 2.4% 3% 1% k1 k2 k3 k4
ee ee ee ee
Week 24 1 89 1.1% 3% 1% W W W W
Week 25 2 86 2.3% 3% 1%
Week 26 1 88 1.1% 3% 1%

Numerator: DENOMINATOR:
Month # Infections # discharges for % of infections Median Stretch Goal
for Month Month
Jan 7 87 8.0% 8.2% 1%
Feb 9 88 10.2% 8.2% 1%
Mar 11 91 12.1% 8.2% 1%
Apr 7 82 8.5% 8.2% 1%
May 9 88 10.2% 8.2% 1%
Jun 8 80 10.0% 8.2% 1%
Jul 7 84 8.3% 8.2% 1% 13%

Aug 4 86 4.7% 8.2% 1% 12%

Sep 3 87 3.4% 8.2% 1% 11%
10%
9%
8%

rcent
7%
6%
 13%
12%
11%
Oct 2 82 2.4% 8.2% 1% 10%
Nov 2 92 2.2% 8.2% 1% 9%
Dec 1 97 1.0% 8.2% 1% 8%

Percent
7%
6%
5%
4%
3%
2%
1%
0%
Jan Feb

Exercise in Run Chart Power Point Presentation

TITLE: Percentage of Infections per month on Ward 6 South
Numerator: Number of Ward 6 Sth patients with an infection for month.
Denominator: Number of patients discharged from Ward 6 Sth for month.

Month % of infections Median Stretch

Goal
18%
Jan 9.0% 6.5% 1%
Feb 15.0% 6.5% 1% 16%
Mar 10.0% 6.5% 1%
Apr 14.0% 6.5% 1%
May 17.0% 6.5% 1% 14%
Jun 7.0% 6.5% 1%
Jul 6.0% 6.5% 1% 12%
Aug 5.7% 6.5% 1%
10%

Percentage
8%
Centre Line - M

6%
 14%

12%

Sep 3.7% 6.5% 1% 10%

Percentage
Oct 2.9% 6.5% 1%
Nov 1.6% 6.5% 1% 8%
Dec 1.0% 6.5% 1% Centre Line - M

6%

4%

2% Stretch Go

0%
Jan Feb

Number of Home
Day of week visits Median Stretch Goal

Mon 10 9 20
Tue 11 9 20
Wed 9 9 20
Thu 15 9 20
Fri 12 9 20

er of Home visits per day

Mon 2 9 20
Tue 11 9 20
25
Wed 5 9 20
Thu 8 9 20
Fri 6 9 20 20

15

10
 Number of Home visits per d
25

20
Mon 19 9 20
Tue 11 9 20
20 15
Wed 5 9
Thu 5 9 20
Fri 5 9 20
10
Mon 6 9 20
Tue 3 9 20
Wed 9 9 20 5
Thu 11 9 20
Fri 14 9 20
0
16 9 20 Mon Tue Wed

Patients in
Days Wait for 18
Chronological order
Outpatient Clinic Median Stretch Goal

ng for Outpatient Clinical Appointment

Appointment
16

Patient 1 10 6 3
14
Patient 2 11 6 3
Patient 3 9 6 3
12
Patient 4 15 6 3
Patient 5 12 6 3
3 10
Patient 6 2 6
Patient 7 4 6 3
Patient 8 5 6 3 8

4
 12

Days waiting for Outpatient Clinica

10

8
Patient 9 8 6 3
Patient 10 6 6 3 6
Patient 11 16 6 3
Patient 12 11 6 3 4
Patient 13 5 6 3
Patient 14 5 6 3 2
Patient 15 5 6 3
Patient 16 3 6 3
0
Patient 17 3 6 3
t1 t2 t3
Patient 18 4 6 3 tien tien tien
Pa Pa Pa
Patient 19 3 6 3
Patient 20 11 6 3
Patient 21 6 6 3

Mental Health patient - Hours in Seclusion

Patients in
Chronological order Hours in Seclusion Median Stretch Goal
160
Patient 1 10 52 3
Patient 2 18 52 3
Patient 3 84 52 3 140
Patient 4 25 52 3
Patient 5 52 52 3
120
Patient 6 63 52 3
Patient 7 72 52 3
100

Hours in Seclusion
Patient 8 84 52 3
Patient 9 96 52 3
Patient 10 107 52 3 80

60

40
 100

Hours in Seclusion
80
Patient 11 145 52 3
Patient 12 52 52 3
60
Patient 13 45 52 3
Patient 14 73 52 3
Patient 15 53 52 3 40
Patient 16 51 52 3
Patient 17 43 52 3
20
Patient 18 37 52 3
Patient 19 23 52 3
Patient 20 21 52 3 0
1 2 3
3 nt nt nt nt
Patient 21 19 52 atie atie atie atie
P P P P
 PDSA cycles
commenced

Patients with Sepsis in ED: Minutes from Diagnosis to administration of 1st Antibiotics
Run Chart
Minutes Stretch Goal <60 minutes Median
Minutes
300

PDSA - Sepsis Pathway

250
introduced

200

150

100 Median 80
 150

100 Median 80

50
Stretch Goal 60 mins

0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
ent ent ent ent ent ent ent ent ent nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 5 nt 5
ti ti ti ti ti ti ti ti ti e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati

asing of Median line (see graph below): Median line is calculated for both pre & post intervention to demonstrate the change in the median (showing the effect of t
In the table to the left, the median line is re-calculated at patient 32 onwards.

Sepsis Patients in ED - Minutes from Diagnosis to administration of 1st Antibiotics

Run Chart
Minutes Centre Line Stretch Goal <60 minutes
Minutes Median
300

250
PDSA - Sepsis Pathway in-
troduced

200
250
PDSA - Sepsis Pathway in-
troduced

200

150
Median 110 mins
Pre-Intervention

100

Stretch Goal 60 mins

50
Median 57 mins
Post-Intervention

0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
ent ent ent ent ent ent ent ent ent nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 1 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 2 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 3 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 4 nt 5 nt 5 n
ti ti ti ti ti ti ti ti ti e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e
P a P a P a P a P a P a P a P a P a P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati P ati
ne and Stretch Goal
matically calculates the median for you.

ch Goal is an aspirational target).

Percentage of Infections on Ward 5 West Example data

Run Chart only
Operational Definition: Numerator: # infections for month.
Denominator: # patients discharged for month (# infected + # not infected)
Rate % Median Stretch Goal PDSA

12%
PDSA

10%

8%

6%
10%

8%

6%

4%

2%

0%
18 18 r-1
8
r-1
8 18 18 l-1
8 18 18 t-1
8 18 c-1
8 19 19 r-1
9
r-1
9 19 19 l-1
9 19 19 t-1
9 19 c-1
9 20
n- b- y- n- g- p- v- n- b- y- n- g- p- v- n-
Ja Fe M
a A p
M
a Ju Ju A u Se Oc No De Ja Fe M
a A p
M
a Ju Ju A u Se Oc No De Ja
 (Mean) line and Stretch Goal

ch Goal is an aspirational target).

Post Operative Infection rate for General Surgery Unit per Month
Run Chart
Numerator: # Post operative infections for month. Denominator: # Operations for month.

Rate % Average (centre line) Stretch Goal

12%

10%

8%

6%
Percent

4%
 Percent

0%
2%
4%
6%
8%

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

Sep-18

Oct-18

Nov-18

Dec-18

Jan-19

Feb-19

Mar-19

Apr-19

May-19

Jun-19

Jul-19
# incidents / (Occupied Bed Days/1000)

Change Ideas
tested via
PDSA Fall Rate per 1000 Occupied Bed Days
Run Chart
Calculation: # Fall incidents / (Occupied
Rate per 1000 Occupied Bed Days
Bed D
Stretch Goal
14

12

10
s per 1000 OBDs

8
 10

Number of Falls per 1000 OBDs

8

0
18 18 18 18 18 18 18 18 18 t-18 -18 -18 -19 -19 r-19 r-19 -19 -19 l-19 -19 -19
n- eb- ar- pr- ay- un- Jul- ug- ep- v c n b y n Ju Aug Sep
Ja F M A M J A S Oc No De Ja Fe Ma Ap Ma Ju
 Patient 17
Patient 18
Patient 19
Patient 20
Patient 21
Patient 22
Patient 23
Patient 24
Patient 25
Patient 26
Patient 27

Run Chart
Patient 28
Patient 29
Patient 30
Patient 31
Patient 32

Patients in chronological order

Turn around time of test (Minutes)
Patient 33
Patient 34
Patient 35
Patient 36
Patient 37
round Time of Blood Test Results (minutes)

Patient 38
Patient 39
Patient 40
Patient 41
Patient 42
Patient 43
Patient 44
Patient 45
Patient 46
Patient 47
only

Patient 48
Patient 49
Patient 50
Example data

Patient 51
Patient 52
Patient 53
 Patient 17
Patient 18
Patient 19
Patient 20
Patient 21
Patient 22
Patient 23
Patient 24
Patient 25
Patient 26
Patient 27
Patient 28
Patient 29
Patient 30
Patient 31
Patient 32
Patients in chronological order

Patient 33
Patient 34
Patient 35
Patient 36
Patient 37
Patient 38
Patient 39
Patient 40
Patient 41
Patient 42
Patient 43
Patient 44
Patient 45
Patient 46
Patient 47
Patient 48
Patient 49
Patient 50
Patient 51
Patient 52
Patient 53
 Example data
Blood Test Turn Around Times (minutes)
Run chart only

Turn around time of test (Minutes) Median

 t6 t7 t8 t9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
en tien tien tien ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent
P a P a P a ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa

Patients in chronological order

Too Many Runs

 Blood Test Turn Around Times (minutes)
Run Chart Example data
only
100 Turn around time of test (Minutes) Median

90

80

70

60
Minutes

50

40

30

20

10

0
t1 t2 t3 t4 t5 t6 t7 t8 t9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
ti en ti en ti en ti en ti en ti en ti en ti en ti en ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti
Pa
ti

Patients (seen in Chronological Order)

Count (number) of Incidents of post-operative bleed Example data
Run Chart only
# post-operative bleed incidents Median Stretch Goal = 0
Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Percentage of Venous Thromboembolism incidents

after Elective Surgery Example data
Run Chart only

% of VTE cases Median Stretch Goal = 0%

 PDSA cycles com-
menced June
ch goal = 0%

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

mbolism (VTE) risk

Percentage of elective surgery patients screened pre-operatively for Venous

Thromboembolism (VTE) risk Example data
Run Chart
only
% of patients screened Median Stretch Goal

PDSA cycles com-

menced June
 PDSA cycles com-
menced June

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Percentage of elective surgery patients at risk of VTE who receive prophy-

laxis (Blood thinning medication) Example
Run Chart data only
100% % patients at risk of VTE who receive prophylaxis medication Median Stretch Goal

95%

90%

85%

80%

75%
PDSA cycles com-
menced June
90%

85%

80%

75%
PDSA cycles com-
menced June

70%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Surgical Site Infection Rate per 1000 Occupied Bed Days

Run chart Example data
Rate of infections per 1000 OBDs Median
only
8

7
er of Infections per 1000 OBD

3
 7

Number of Infections per 1000 OBD 6

0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Axis Title

er of days between surgical site infection incidents

Run Chart Example data
only
Number of Days between Infections Median

PDSA 2

PDSA 3
 PDSA 2

PDSA 3

Feb 18th 23rd 3rd 9th 2nd 13th 18th 23rd 28th 1st 4th 8th 11th 22nd 28th
Feb Feb Mar Mar Apr Apr Apr Apr Apr May May May May May May
umber of Surgical cases between infections
Run Chart Example data
only
Number of surgery cases between infections Median

PDSA 2

PDSA 1

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Date of Infection
 Do not alter this column Do not alter this
(it calculates column
automatically) (it calculates
section automatically)

Median Change ideas Med

Women 8 Women 9 Women 10 Median
Minutes tested via PDSA from labour ward

45 27 27.0 12.0
21.0 12.0
30
22.0 12.0
18.5 12.0 PDSA 1 PDSA 1
17 32 8 15.0 12.0
9 21 15.0 12.0 PDSA 2 25
14.0 12.0
12 15.0 12.0
8 25 9.0 12.0 PDSA 3 20 PDSA 2

Minutes waiting
15
Median
 25

20 PDSA 2
11 15.5 12.0
14 12 12.0 12.0

Minutes waiting
7 3 12.0 12.0 15
8 8.0 12.0 Median
8 6.5 12.0 PDSA 4
5 7 8 6.5 12.0 10
4 5.0 12.0
8 3 5.0 12.0
4 4.0 12.0
5
4 4.0 12.0
3 5 2 3.0 12.0

0
k1 k2 k3 k4 k5 k6 k7
ee ee ee ee ee ee ee
W W W W W W W

164 # observations

Interpretation of a Run Chart

Shift, Trend & Astronomical Data Point
are signals of 'non-random' variation

# Median
 Interpretation of a Run Chart
Shift, Trend & Astronomical Data Point
are signals of 'non-random' variation

# Median
Astronomical Data Point
(outlier)

SHIFT
>6 points above or below the cent- TREND
ral line > 5 points up or down.
Values on centre line do not add to or break Like values do not add or break a trend.
a shift.

Central line (Me-

dian)
 Central line (Me-
dian)

8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
ent ent nt1 nt1 nt1 nt1 nt1 nt1 nt1 nt1 nt1 nt1 nt2 nt2 nt2 nt2 nt2 nt2 nt2 nt2 nt2 nt2 nt3 nt3 nt3 nt3 nt3 nt3 nt3
ati Pa
ti tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie tie
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa

X-Axis in chronological order

Percentage of Infections
Run Chart Example
Numerator: # Infections for week. Denominator: # discharges for week only
% of infections Median Stretch Goal
8%

7%

6%

5%

4%
Percent

3%
 6%

5%

4%
Percent

3%

2%

1%

0%
k1 k2 k3 k4 k5 k6 k7 k8 k9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
ee ee ee ee ee ee ee ee ee eek eek eek eek eek eek eek eek eek eek eek eek eek eek eek eek eek
W W W W W W W W W W W W W W W W W W W W W W W W W W

E
x
a
m
p
l
e
d
a
Percentage of Infections per Month tExample data
Run Chart
Numerator: # Infections for month a only
Denominator: # discharges for month (pts with + without infection)
% of infections Median Stretch Goal o
n
13% l
12% y
11%
10%
9%
8%
rcent

7%
6%
 Denominator: # discharges for month (pts with + without infection)
% of infections Median Stretch Goal o
n
13% l
12% y
11%
10%
9%
8%
Percent

7%
6%
5%
4%
3%
2%
1%
0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Percentage of Infections per month on Ward 6 South Example data

Run Chart
Numerator: Number of Ward 6 Sth patients with an infection for month. only
Denominator: Number of patients discharged from Ward 6 Sth for month.
% of infections Median Stretch Goal

18%

16% PDSA
Tests
14%

12%

10%

8%
Centre Line - Median

6%
 Tests
14%

12%

10%

8%
Centre Line - Median

6%

4%

2% Stretch Goal

0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

E
x
a
m
p
l
e
d
a
Number of Home Visits Per Day t
Run Chart a
er of Home visits per day

Number of Home visits Median Stretch Goal o

n
25 l
y
20

15

10
 o
Number of Home visits per d
Number of Home visits Median Stretch Goal
n
25 l
y
20

15

10

0
Mon Tue Wed Thu Fri Mon Tue Wed Thu Fri Mon Tue Wed Thu Fri Mon Tue Wed Thu Fri

Days Wait for Outpatient Clinic Appointment Example data

Run Chart
only
Days Wait for Outpatient Clinic Appointment Median Stretch Goal

18
ng for Outpatient Clinical Appointment

16

14

12

10

4
 12
Days waiting for Outpatient Clinica
10

0
t1 t2 t3 t4 t5 t6 t7 t8 t9 10 11 12 13 14 15 16 17 18 19 20 21
tien tien tien tien tien tien tien tien tien ent ent ent ent ent ent ent ent ent ent ent ent
Pa Pa Pa Pa Pa Pa Pa Pa Pa ti ti ti ti ti ti ti ti ti ti ti ti
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa

Duration of Seculsion Example data

Run Chart only
Hours in Seclusion Median
160

140 PDSA 1

120

100
Hours in Seclusion

PDSA 2
80

60

40
 100
Hours in Seclusion

PDSA 2
80

60

40

20

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt
atie atie atie atie atie atie atie atie atie tie tie tie tie tie tie tie tie tie tie tie tie
P P P P P P P P P Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa
n of 1st Antibiotics Example
data only

hway

Median 80 mins (Central Line)

 Median 80 mins (Central Line)

43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
nt ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent
ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti ti
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa Pa

dian (showing the effect of the PDSAs)

ntibiotics Example data

only
<60 minutes

Pathway in-
uced
 Pathway in-
uced

2 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt nt
tie atie atie atie atie atie atie atie atie atie atie atie atie atie atie atie atie atie
P P P P P P P P P P P P P P P P P
 Example data
only

SA
 9 19 9 20
t-1 v- c-1 n-
Oc No De Ja
 P

Unit per Month Nu

Example data only
Operations for month.

Stretch Goal
12%

10%

8%

6%
Percent

4%

2%
 Apr-19

May-19

Jun-19

Jul-19

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

Jan-20

Percent
tor
X-axis

nator
month,
Date or

on # e.g.:
Observati

or date of

Denomi
week, day

Numera
audit etc...
0%
2%
4%
6%

4
87

Jan-18 Jan-18
5
78

Feb-18 Feb-18
6
87

Mar-18 Mar-18
7
89

Apr-18 Apr-18
6
87

May-18 May-18
5
76

Jun-18 Jun-18

Jul-18
pied Bed Days
Example
data only
ccupied Bed Days/1000)
Stretch Goal Median
 9 9 9 9 9 9 9 9 0 0 0 0 0 0
-1
ay Jun
-1
ul-1 g-1 p-1 ct-1 ov-1 ec-1 n-2 b-2 ar-2 pr-2 ay-2 n-2
J Au Se O N D Ja Fe A Ju
M M M
Too Few Runs
 Blood Test Turn Around Tome (Minutes) Example
ample data Run Chart data only
only Turn around time of test (Minutes) Median

90
Too Few Runs
80

70

60

50
Minutes

40

30

20

10

27 28 29 30 0
nt ent ent ent t1 t2 t3 t4 t5 t6 t7 t8 t9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Pa
ti
Pa
ti
Pa
ti
ti en tien tien tien tien tien tien tien tien ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati

Axis Title
0
t1 t2 t3 t4 t5 t6 t7 t8 t9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
ti en tien tien tien tien tien tien tien tien ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent ent
Pa Pa Pa Pa Pa Pa Pa Pa Pa Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati Pati

Axis Title
 Median weekly wait time (minutes)
from labour ward to theatre for an emergency Caesarean Section
n=164 Example data
Run Chart
Median Minutes only
Median

PDSA 1

PDSA 2
PDSA 3

PDSA 4
 PDSA 2
PDSA 3

PDSA 4

3 k4 k5 k6 k7 k8 k9 0 1 2 3 4 5 6 7 8 9 0
ee ee ee ee ee ee k1 k1 k1 k1 k1 k1 k1 k1 k1 k1 k2
W W W W W W ee ee ee ee ee ee ee ee ee ee ee
W W W W W W W W W W W
wn.
k a trend.

Central line (Me-

dian)
 Central line (Me-
dian)

32 t3
3
t3
4
t3
5
t3
6
n n n n
tie tie tie tie
Pa Pa Pa Pa

Example data
only
 5 6
e k 2 ek 2
e e
W W

E
x
a
m
p
l
e
d
a
tExample data
a only
n)
o
n
l
y
n)
o
n
l
y

Nov Dec

xample data
only
ov Dec

Too much white

adjust Y-axis min & max
values
 Too much white
adjust Y-axis min & max
values

hu Fri

ample data
only
19 20 21
ent ent
ti ti
Pa Pa

mple data
only
 Post Operative Infection rate for General Surgery Unit per Month
Run Chart Example data on
Numerator: # Post operative infections for month. Denominator: # Operations for month.

Rate % Average (centre line) Stretch Goal

 May-18

Jun-18

4
78
Jul-18 Jul-18

5
87
Aug-18 Aug-18

6
89
Sep-18 Sep-18

7
87
Oct-18 Oct-18

8
89
Nov-18 Nov-18

7
87
Dec-18 Dec-18

6
89
Jan-19 Jan-19

5
90
Feb-19 Feb-19

4
87
Mar-19
5 Mar-19

78
Apr-19 Apr-19
4
87

May-19 May-19
5
87

Jun-19 Jun-19
7
89

Jul-19 Jul-19
8
89

Aug-19 Aug-19
9
87

Sep-19 Sep-19
5
87

Oct-19 Oct-19
4
67

Nov-19
Nov-19

Dec-19

Jan-20
 Example
data only

ns

4 25 26 27 28 29 30
e nt ent ent ent ent ent
ati Pati Pati Pati Pati Pati
4 25 26 27 28 29 30
e nt ent ent ent ent ent
ati Pati Pati Pati Pati Pati
e
max
e
max
Example data only
 Oct-19

Nov-19

Dec-19

4
89
Dec-19
Jan-20

4
87
Jan-20
Infection Examples - Different run charts for different situations
Incidents of Surgical Site Infections

# Infections for
Month Median
month

Jan 5 6
Feb 3 6
Mar 2 6
Incidents of Surgica
Apr 5 6 10
Run Ch
# Infections for mon

May 6 6

Count (#)
9

Jun 6 6 8

7
Jul 4 6 6

Aug 6 6 5

Sep 7 6 4

Oct 9 6
3

Nov 7 6 1

Dec 8 6 0
Jan Feb Mar Apr May Ju
Advanced Advanced
Measurement: Measurement:
Use this column of Use this column of
data to produce a data to produce a
C Chart C Chart
Percentage (Proportion) of Surgical Site Infections
Percentage of Surg
Month Numerator: DENOMINATOR: % of infections Median % ofRun C
infection
# Infections # Surgical 12%
for month discharges for
month
10%

Jan 5 87 6% 7%
Feb 3 85 4% 7% 8%

Mar 2 91 2% 7%

Percent
Apr 5 97 5% 7% 6%
May 6 84 7% 7%
Jun 6 83 7% 7% 4%
Jul 4 87 5% 7%
Aug 6 89 7% 7% 2%
Sep 7 80 9% 7%
Oct 9 82 11% 7% 0%
Nov 7 84 8% 7% Jan Feb Mar Apr May
Dec 8 86 9% 7%
Advanced Advanced Advanced
Measurement: Measurement: Measurement:
Use this column of Use this column of Use this column of
data to produce a data to produce a data to produce a
P Chart P Chart P Chart
Surgical Site Infection Rate per 1000 Occupied Bed Days
Month # Infections Occupied Bed Rate of infections
for month Days per Month per 1000 OBDs
for Surgery
1000 OBD/1000

Jan 5 1648 1000 1.6 3

Feb 3 1577 1000 1.6 2
Mar 2 1794 1000 1.8 1
Apr 5 1324 1000 1.3 4
May 6 1323 1000 1.3 5
Jun 6 1765 1000 1.8 3
Jul 4 1019 1000 1.0 4
Aug 6 1455 1000 1.5 4
Sep 7 1180 1000 1.2 6
Oct 9 1334 1000 1.3 7
Nov 7 1825 1000 1.8 4
Dec 8 1487 1000 1.5 5
 Advanced Advanced Advanced
Measurement: Measurement: Measurement:
Use this column to Use this column to Use this column
produce a produce a to produce a
U Chart U Chart U Chart

Days Between Infection incidents

Number of Days
Date of Infection between Infections Median
3rd Jan 5.5
15th Jan 12 5.5
22nd Jan 7 5.5
25th Jan 3 5.5
30th Jan 5 5.5

Days between Infection cases

7th Feb 8 5.5 Number of days between surg
18th Feb 11 5.5 Run Infe
Number of Days between Ch
26
23rd Feb 5 5.5 24
3rd Mar 8 5.5 22

9th Mar 6 5.5 20

18
2nd Apr 24 5.5
16
13th Apr 11 5.5 14
18th Apr 5 5.5 12
23rd Apr 5 5.5 10

28th Apr 5 5.5 8

1st May 3 5.5 6

4
4th May 3 5.5
2
8th May 4 5.5
0
11th May 3 5.5 3rd 15th 22nd 25th 30th 7th 18th 23rd 3rd 9th
Jan Jan Jan Jan Jan Feb Feb Feb Mar Ma
Date o
 Days b
8
6
4
2
0
3rd 15th 22nd 25th 30th 7th 18th 23rd 3rd 9th
Jan Jan Jan Jan Jan Feb Feb Feb Mar Ma
22nd May 11 5.5 Date o
28th May 6 5.5
Advanced Advanced
Measurement: Measurement:
Use this column of Use this column of
data to produce a data to produce a
T Chart T Chart

Number of Surgical Cases between Surgical site Infection incidents

Number of Surgical
Date of Infection cases (operations) Median
between Infections
8th Jan 25 32
19th Jan 32 32
24th Jan 21 32
28th Jan 21 32
30th Jan 32 32
6th Feb 21 32 Number of Surgical cases (surgical operati
Run Chart
18th Feb 11 32 Number of Surgical cases (operations) between In

23rd Feb 25 32 100

of Surgical Cases

90

80

70

60

50
 Number of Surgical cases (surgical operati
Run Chart
Number of Surgical cases (operations) between In

100

Number of Surgical Cases

3rd Mar 15 32 90
9th Mar 32 32 80
2nd Apr 15 32 70
13th Apr 23 32
60
16th Apr 11 32
50
23rd Apr 34 32
40
28th Apr 45 32
30
1st May 54 32
20
4th May 57 32
10
8th May 64 32
0
13th May 72 32 8th 19th 24th 28th 30th 6th 18th 23rd 3rd 9th 2nd
Jan Jan Jan Jan Jan Feb Feb Feb Mar Mar Apr
22nd May 63 32
29th May 89 32 Date of Infe
Advanced Advanced
Measurement: Measurement:
Use this column of Use this column of
data to produce a data to produce a
G Chart G Chart
 E
x
a
m
p
l
e
d
a
Incidents of Surgical Site Infections t
0
Run Chart
# Infections for month Median a
9
o
8 n
7 l
6
y
5

0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
 Percentage of Surgical Site Infections
Example data
% ofRun Chart Median
infections
only
2%

0%

8%

6%

4%

2%

0%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
 E
x
a
Median m
p
l
e

d
Surgical Site Infection Rate per 1000 Occupied Bed Days
Run Chart a
4 Rate of infections per 1000 OBDs Median t
4 8
Number of Infections per 1000 OBD

a
4 7

4 6
o
4 n
5 l
4 y
4
4
4 3

4 2

4 1
4
0
4 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
 3

Number
2

0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

E
x
a
m
p
l
e
d
Number of days between surgical site infection incidents a
Run Infections
Number of Days between Chart Median
t
a
o
n
l
y

th 22nd 25th 30th 7th 18th 23rd 3rd 9th 2nd 13th 18th 23rd 28th 1st 4th 8th 11th 22nd 28th
n Jan Jan Jan Feb Feb Feb Mar Mar Apr Apr Apr Apr Apr May May May May May May
Date of Infection
th 22nd 25th 30th 7th 18th 23rd 3rd 9th 2nd 13th 18th 23rd 28th 1st 4th 8th 11th 22nd 28th
n Jan Jan Jan Feb Feb Feb Mar Mar Apr Apr Apr Apr Apr May May May May May May
Date of Infection

E
x
a
m
p
l
e
d
ber of Surgical cases (surgical operations) between infectionsa
Run Chart t
Number of Surgical cases (operations) between Infections Median a
o
n
l
y
 d
ber of Surgical cases (surgical operations) between infectionsa
Run Chart t
Number of Surgical cases (operations) between Infections Median a
o
n
l
y

24th 28th 30th 6th 18th 23rd 3rd 9th 2nd 13th 16th 23rd 28th 1st 4th 8th 13th 22nd 29th
Jan Jan Jan Feb Feb Feb Mar Mar Apr Apr Apr Apr Apr May May May May May May

Date of Infection
Procedure for Interpreting Run Charts (adapted from IHI web site)
www.ihi.org

Run Charts Rules Summary

Signals of non-random patterns:
1. Shift - 6 or more consecutive points either all
above or all below the median
2. Trend - 5 or more consecutive points all going
up or all going down.
3. Runs - Too few or too many runs.
4. Astronomical point - A point obviously different
from the rest, "everyone agrees." This rule is
subjective, unlike rules 1-3, which are
probability based.
See Perla et al. (2010) for further explanation and details
1/3/2015 3
 N not on median Lower limit Upper limit
26 9 19

Expected Runs Table

27 10 19
28 10 20
29 10 20
30 11 21
Total number of Lower limit for Upper limit for 31 11 22
data points on the number of the number of 32 11 23
the run chart runs (< than this runs (> than this 33 12 23
that do not fall number runs is number runs is 34 12 24
on the median 'too few') 'too many') 35 12 24
10 3 9 36 13 25
11 3 10 37 13 25
Checking for too 38 14 26
12 3 11
many or too few 13 4 11 39 14 26
40 15 27
runs on a run chart. 14 4 12
41 15 27
15 5 12
 32 11 23
the run chart runs (< than this runs (> than this 33 12 23
that do not fall number runs is number runs is 34 12 24
on the median 'too few') 'too many') 35 12 24
10 3 9 36 13 25
11 3 10 37 13 25
Checking for too 38 14 26
12 3 11
many or too few 13 4 11 39 14 26
40 15 27
runs on a run chart. 14 4 12
41 15 27
15 5 12
Table is based on 42 16 28
16 5 13 43 16 28
about a 5% risk of 17 5 13 44 17 29
failing the run test 18 6 14 45 17 30
19 6 15 46 17 31
for random patterns 47 18 31
20 6 16
of data. 21 7 16 48 18 32
49 19 32
22 7 17
50 19 33
23 7 17
51 20 33
24 8 18 52 20 34
25 8 18 53 21 34
54 21 35
55 22 35
56 22 35
Source: Table 1, Perla et al. (2010), p. 49. 57 23 36
58 23 37
59 24 38
1/3/2015 2
60 24 38
Lower limit Upper limit
9 19
10 19
10 20
10 20
11 21
11 22
11 23
12 23
12 24
12 24
13 25
13 25
14 26
14 26
15 27
15 27
11 23
12 23
12 24
12 24
13 25
13 25
14 26
14 26
15 27
15 27
16 28
16 28
17 29
17 30
17 31
18 31
18 32
19 32
19 33
20 33
20 34
21 34
21 35
22 35
22 35
23 36
23 37
24 38
2
24 38
Statistical Process Control Chart Templates for QI Macros
This section is for Applied Measurement participants
Software that enables the creation of Statistical Process Control (SPC) charts is essential for understanding Shewhart control charts.
There are many software options available at varying levels of sophistication and pricing.
Appendix 6 of 'The Health Care Data Guide' (2011) by Provost and Murray provides a list of characteristics to consider when Purchasing SPC Software, page 211.

QI Macros™ is software that assists with analysis of data for quality improvement.
It works as an add-in to Excel and is designed for use by non-statisticians.
The software is available for free 30-day trial at: https://www.qimacros.com/qi-macros/

You will need an administrator to install it for you on your work computer.
The QI Macros website contains multiple tutorials and videos to assist users. www.qimacros.com

C Chart (Attribute - Count data)

X-axis
Date or Observation # eg:
month, week, day or date of Count Data Change ideas tested via PDSA
audit etc...
 Applied Applied Measurement:
Measurement: Use this column of data
Use this column of to produce a
data to produce a C Chart (Attribute data)
C Chart (Attribute
data)

U Chart (Attribute - Count Data for a Rate)

Example: Incident Rate per 1000 Occupied Bed Days (Attribute Data). Calculation: # incidents / (O
 X-axis
Date or Observation # # incidents Occupied Bed Days / 1000 Change ideas tested via PDSA
eg: month, week, day
or date of audit etc...
 Applied Applied Measurement:
Measurement: Use this column to
Use this column to produce a
produce a U Chart or a C Chart
U Chart or a C Chart

P Chart Template (Attribute - Classification Data for a %)

X-axis Numerator Denominator Change ideas tested via
Date or Observation in (top number in the (bottom number in the PDSA
CHRONOLOGICAL fraction) fraction)
ORDER eg: month,
week, day, Patient
1,2,3 or date of audit
etc...
 Applied Applied Measurement: Applied Measurement:
Measurement: Use this column of data Use this column of data to
Use this column of to produce a produce a
data to produce a P Chart P Chart
P Chart

I Chart - Continuous Data

Y-Axis to be a MEASURE ie: time (mins, hours), height, weight, volume, $, Throughput - # of surgeries etc.
X-axis
Date or Observation # eg:
month, week, day or date of Measure: Change ideas tested via PDSA
audit etc...
 Applied Applied Measurement:
Measurement: Use this column of data
Use this column of to produce a
data to produce a I Chart (Measure)
I Chart (Measure)
X Bar & S Chart Template (Continuous Data)
Continuous data - MEASURE ie: time (mins, hours), turn-around time, wait time for treatment (hours or weeks), height, weight, vo

X-axis Case 1 Case 2 Case 3 Case 4

Time period Measure Measure Measure Measure
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12
Week 13
Week 14
Week 15
Week 16
Week 17
Week 18
Week 19
Week 20
Week 21
Week 22
Week 23
Week 24
Week 25
Applied Applied Measurement: Applied Measurement: Applied Measurement: Applied Measurement:
Measurement: Use this column of data Use this column of data to Use this column of data to Use this column of data
Use this column of to produce a produce a produce a to produce a
data to produce a X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart
X Bar & S Chart

T Chart - Time (Days/Weeks) between incidents

Date of Incident Number of Days between Change ideas tested via PDSA
Incidents
Date of 1st incident
Date of 2nd incident # days from last incident
 Applied Applied Measurement:
Measurement: Use this column of data
Use this column of to produce a
data to produce a T Chart
T Chart

G Chart - Number of Cases between incidents

Number of infections
Date of Incident between Surgery cases Change ideas tested via PDSA

Date of 1st incident

Date of 2nd incident # cases from last incident
 Advanced Advanced Measurement:
Measurement:
Use this column of Use this column of data
data to produce a to produce a
G Chart G Chart
I Macros
control charts.

r when Purchasing SPC Software, page 211.

Calculation: # incidents / (Occupied Bed Days/1000)
- # of surgeries etc.
eatment (hours or weeks), height, weight, volume, $, Throughput - # of surgeries etc.
Case 5 Case 6 Case 7 Case 8 Case 9 Case 10
Measure Measure Measure Measure Measure Measure
Applied Measurement: Applied Measurement: Applied Measurement: Applied Measurement: Applied Measurement: Applied Measurement:
Use this column of data Use this column of data Use this column of data Use this column of data Use this column of data Use this column of data
to produce a to produce a to produce a to produce a to produce a to produce a
X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart X Bar & S Chart
Change ideas tested via PDSA
Instructions on how to create a Run chart