Table 8

 Barriers to SPC application*

*We found reports of barriers in 15 articles. They formed 10 categories which are grouped into three broad areas.
People related barriers
1Lack of knowledge on how to apply SPC correctly16,35,37,51Even though control charts, constructed correctly, may be easy to use, not all healthcare professionals and managers have sufficient SPC knowledge
2At first, SPC may represent a new and challenging way of thinking18,40“It is not at all surprising that many persons avoid involvement in statistical process control. The statistical procedures developed in industry to monitor production processes are somewhat different from those employed in biostatistics and social science applications. Many find it difficult to adjust to these procedures and to apply statistical process control techniques to situations in health care settings” (McKenzie,18 p 81)
3If SPC application is not perceived as helpful, it may not succeed39,65“Whereas Finison et al.[Ref] claim that the mean and standard deviation are simple and easy for staff to understand, the staff involved in this study found them difficult to perceive. This is partly accounted for by the staff’s resistance, as it seemed that they did not want to understand the results of the figures. The staff expected the investigators to tell them what to do and did not want to process the results and the issues underlying them” (Hyrkas and Lehti,65 p 186)
Data collection and chart construction related barriers
4Collection and attribution of data to different hospital units for SPC application can be difficult61In the case of hospital acquired infections, investigators found that it was hard to assign new cases to the correct ward or unit’s control chart. “The few disadvantages of this approach primarily concern implementation. The ability to assign a new MRSA case to a specific ward rarely can be completely accurate. We attempt to minimize this imprecision by encouraging the input of ward staff in any discussions or debates as to where a patient acquired the MRSA” (Curran et al,61 p 17)
5Finding the right level of aggregation of data for SPC application can be difficult and require trade-offs61Continuing with the example of hospital acquired MRSA infections, finding the best level of data aggregation was a barrier: “If the control chart includes too many wards, then staff may feel the responsibility lies elsewhere and they may not be inclined to use the feedback to alter their practices. Further, if the chart contains information from too many departments or units, it sometimes can mask local problems or out-of-control data. [Furthermore, monitoring] a large number of units on individual charts also can decrease the overall specificity and increase the false-alarm rate, especially if [2 sigma] warning limits are used as control limits” (Curran et al,61 pp 16–8)
6Data collection and analysis can be time consuming and costly17,19,37,39“Other real obstacles that challenge physicians are the time required for and the financial costs of data collection and analysis. ... Certainly, measurement may consume valuable resources” (Nelson et al,37 p. 465)
7Constructing the most appropriate control chart can be difficult30“The most difficult task is deciding which probability distribution, and thus which control chart, is most appropriate for the data, and then choosing homogenous and rational subgroups to analyze” (Shahian et al,30 p 1356)
8Lack of access to reliable data in a timely fashion can be a barrier to real-time SPC application47Discussing care pathways in cardiac surgery, one group found that “accurate process data are difficult and expensive to obtain. Data obtained from hospital and medical records data systems are often inaccurate, temporally inefficient, and not focused on daily patient events[.] Among the difficulties with optimizing outcome-based cardiac surgical care are the expense and problems with [multi-institutional] databases, including lack of standardization, cost of dedicated data entry/delivery personnel, and lack of timely feedback[. Those] systems were not designed to provide rapid feedback of process data, which is necessary if individual practitioners are to effectively manage cardiac surgery pathways” (Ratcliffe et al,47 p 1820)
Information technology related barriers
9Lack of computer power was a barrier to real-time SPC application22“There are several reasons why control charts and other statistical process control techniques have to date not been introduced as tools to improve real-time clinical decision making. These include lack of computer power to perform calculations in real time, inabilities to interface medical monitors with computers and to produce clean measurement with an acceptable signal to noise ratio, and lack of statistical process control training for clinical decision makers” (Laffel et al,22 pp 76–7)
10Software problems can hamper SPC application26One study reported unspecified, and subsequently resolved, software problems as the only barrier to SPC application