Comparison of Control Charts for Poisson Count Data in Healthcare Monitoring

Statistical surveillance is a noteworthy endeavor in many health-care areas such as epidemiology, hospital quality, infection control, and patient safety. Formonitoring hospital adverse events, the Shewhart u-control chart is the most used methodology. One possible issue of the u-chart is that in health-care applications the lower control limit (LCL) is often conventionally set to zero as the adverse events are rare and the sample sizes are not sufficiently large to obtain LCL greater than zero. Consequently, the control chart loses any ability to signal improvements. Furthermore, as the area of opportunity (sample size) is not constant over time, the in-control and out-of-control run length performances of themonitoring scheme are unknown. In this article, on the basis of a real case and through an intensive simulation study,we first investigate the in-control statistical properties of the u-chart. Then we set up several alternative monitoring schemes with the same in-control performances and their out-of-control properties are studied and compared. The aim is to identify themost suitable control chart considering jointly: the ability to detect unexpected changes (usually worsening), the ability to test the impact of interventions (usually improvements), and the ease of use and clarity of interpretation. The results indicate that the exponentially weighted moving average control chart derived under the framework of weighted likelihood ratio test has the best overall performance.