Dear Experts,
1.According to one of our policy the medical assessment should be done within the first 24 hours , the auditing process for the previous month have showed that the average baselines is 04:02 hours (no special cause variation) , my question is , can we see that the process is capable?
Sometimes the average can be misleading, which is why variation around it is important. If you have enough data, you should be able to predict with reasonable assurance the likelihood of the 24-hour mark being violated, and then address the process if it's necessary. You say there's no special-cause variation, but it's still possible that the process won't perform as required (although since the mean seems to be comfortably distant from the upper limit, and the process is in control, it's probably unlikely). The question you need to ask yourself is, "Is there anything in the data that makes me believe that the process needs to be adjusted?" Given the probable number of variables involved, it would be difficult for anyone here to give you definitive advice.
The second case is about the needle stick incidents, we are using c chart to monitor the number of incidents on a monthly basis, the process is stable but the problem is we don’t have a target number of incidents, so in this case how can we know if the process is capable?
At first blush, there's an urge to say that the target number should be zero, but I'm not a fan of the zero defects approach when it's known that defects are inevitable. What number of fatal car accidents is "acceptable"? That's a loaded question, somewhat like the classic "Have you stopped beating your wife" query. The intuitive answer is "none," but we still know that fatal car accidents are inevitable, so it makes no sense to have zero as a goal (imo).
I think that maybe you've skipped a step, and need to do a little PDCA, rather than worrying about a target at this point. Here are some questions you might like to ask:
- How many needle sticks are happening now, over some period of time x?
- Why are they happening? Is there a training issue? Is there any pattern? For example, do needle sticks happen more on a particular shift? Are they more likely to be perpetrated by certain people, or in certain situations (or some combination of the two)?
- Outside of needlessly inflicting pain, what are the risks? We know that transmission of pathogens is a concern, for example.
There are other potential questions, but you get the idea. Once you
know something about the problem, you will be in a better position to develop methods of mitigating it. The reason you are collecting data should be to give you knowledge of how, when and why the problem occurs, and what might be acceptable means of dealing with it. Setting a target at this point probably won't be helpful, unless the target is a meaningful and pragmatic reduction.