Table 6

Benefits of using SPC to improve clinical processes*

		Examples/explanations
*All articles reported benefits, and many reported several. The benefits formed 12 categories which are grouped into three broad areas.
SPC facilitated and documented healthcare process improvement
1	SPC application helped people assess the impact of changes to the process^19,^24,^27,^30,^32–^34,^37,^42,^43,^45,^52,^53,^55,^57,^58,^60,^64,^67,⁶⁸	Many articles reported a helpful role of SPC in determining the effects of interventions made to healthcare processes. Examples include successful effects, adverse effects or a lack of effect
2	SPC application contributed (led) to improvement of healthcare processes^16,^17,^20,^26,^28,^30,^31,^36,^37,^46,^53,^56,⁶⁵	Several articles reported improvement of a healthcare process and attributed that improvement, more or less explicitly, to improvement efforts in general and SPC application in particular (the foundations for such attribution were methodologically weak—for instance, case reports without comparisons).
		For example, investigators evaluating the “door-to-needle-time” (DTNT) for thrombolytic treatment of patients with acute myocardial infarction (AMI) using control charts found that “in the beginning there was considerable variability of DTNT signifying that the process of in-hospital management of patients with AMI was out of statistical control. Shortly after the initiation of formal process analysis DTNTs were reduced significantly and remained within a narrow range, now showing a stable and statistically controlled pattern. Thus, process quality was significantly improved by our efforts” (Bonetti et al,⁴⁶ p 315)
3	SPC application helped people identify areas for improvement^21,^26,^40,^42,^47,^49,^58,⁷⁰	Several investigators identified process performance that was not satisfactory, and hence in need of improvement, using SPC. For instance, investigators applying SPC to the care of patients with asthma concluded that when the care process yields a range of breathing that “is clinically problematic, the care process should be redesigned and monitored to ensure that the problem has been corrected” (Boggs et al,⁴⁰ p 175)
SPC was a useful tool for healthcare management
4	SPC application helped people distinguish special from common cause variation^15,^30,^35,^38,^39,^41,^42,^45,^49,^51,^54,^59,^64,^70,⁷¹	Reflecting one of the tenets of SPC, many articles reported how SPC helped people identify common cause and special cause variation, and understand the difference. Investigators applying SPC to surgical care, for instance, concluded that “plotting data over time and using control chart techniques will tell us whether the variation in a surgical process is stable and predictable or whether variation signals a significant change in the process” (Levett and Carey,⁴² p 358)
5	SPC seen as a valuable QI tool which was easy to use^18,^19,^25,^29,^30,^38,^40,^42,^47,^48,^50,^56,^62,^69,⁷⁰	Many articles report the usefulness of SPC as a tool in healthcare process management and improvement. Investigators at a cardiac surgery department, for example, designed a system for automated data collection and generation of control chart for critical pathway adherence, and concluded that it was “a cost effective method for providing timely feedback. The benefits of timely feedback with the control chart method are strongly suggested by this study” (Ratcliffe et al,⁴⁷ p 1821)
6	SPC enabled valuable prediction of future process performance^30,^35,⁴⁰	A few studies reported the value of being able to predict future performance of stable processes. A predictable outcome was beneficial to the patient, doctor and insurer.³⁰ In asthma care, such prediction enabled clinicians and patients to decide whether to maintain the current care regimen or alter it to improve future outcomes^35,⁴⁰
7	SPC helped describe and quantify process variability^22,^23,³⁵	SPC allowed characterisation of process variability, including variability present in blood pressure measurement²³
SPC helped process stakeholders
8	SPC enabled patients to be partners in clinical management (and research)^35,^38,^40,^50,⁶⁰	SPC enabled patients with chronic conditions to better understand and manage—alone or in partnership with clinicians—their condition, specifically, diabetes mellitus,^38,⁵⁰ hypertension,³⁸ muscular pain⁶⁰ and asthma.³⁵ SPC has also been proposed as a research strategy whereby patients can be active partners in data collection and analysis.³⁸
		In asthma care, for example, when patients control-chart their breathing function the benefits include “knowing each patient’s signals and their meaning; natural limits of the current care process; and having the ability to anticipate this patient’s future level of function given no change in his/her care process[. This] enhances both the patient’s and physician’s ability to meaningfully engage in the process of continuous quality improvement of asthma. [It] elevates the level of communication and dialogue between patients and physicians exponentially beyond that generated by traditional run chart information” (Boggs et al,³⁵ p 561)
9	SPC application improved communication between process actors^35,^36,^52,^63,⁷⁰	SPC provided a common language and facilitated communication between managers and clinicians, or between clinicians and patients. See the example above
10	SPC application enabled (better) informed decision making^21,^26,^35,^44,^54,^61,^63,⁶⁶	SPC helped inform decision making in healthcare organisation governance and management^21,^26,^44,^54,^61,⁶³ and in clinical decision making regarding—or in partnership with—patients.^35,⁶⁶
		Reporting on efforts at the Intermountain Health Care system to improve inpatient acuity level assessment, Shaha concluded that “control charts have given information to delivery-level decision makers which they have never before enjoyed. The system has helped nurse managers better understand the acuity on their units and plan more effectively for appropriate staffing to support patient care. Improved staffing has enhanced teamwork and the quality of work life on these units” (Shaha,²⁶ p 30)
11	SPC empowered process stakeholders^15,^21,^26,^35,^50,^54,⁶¹	SPC had an empowering effect among—for example, patients,^35,⁵⁰ nurse managers,²⁶ a medical assistant,¹⁵ healthcare workers and managers,^21,⁶¹ and board members^21,⁵⁴
12	SPC application helped stakeholders learn about their processes^40,^63,⁶⁸	Stakeholder—or “organisational”—learning was facilitated by SPC application and involved patients,⁴⁰ clinicians^40,^63,⁶⁸ and managers.⁶³
		“Both you and your patient are learners. Let the charts teach you and help you learn what is of practical value to your patients. You will find that learning together is a strong invitation of commitment to the [asthma care] process for both of you” (Boggs et al,⁴⁰ p 175)