A Primer on Quality Improvement Methodology in Neonatology Dan L. Ellsbury, MD, Robert Ursprung, MD, MMSc  Clinics in Perinatology  Volume 37, Issue 1, Pages 87-99 (March 2010) DOI: 10.1016/j.clp.2010.01.005 Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 1 Stable rate of late-onset sepsis in the first year. Following implementation of the change the rate decreased in the second year. Yearly data are representative of the monthly trends. Clinics in Perinatology 2010 37, 87-99DOI: (10.1016/j.clp.2010.01.005) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 2 Sepsis rate decreased in the first year. Following implementation of the change, the rate decreased slightly, then increased in the second year. The change may have worsened the outcome. Despite the mean rate for the second year being half the first year, the monthly trend is showing worsening sepsis rates. Yearly data alone miss this important trend. Clinics in Perinatology 2010 37, 87-99DOI: (10.1016/j.clp.2010.01.005) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 3 Sepsis rate decreased steadily in the first year. Following implementation of the change, the rate continued to steadily decrease. It is unclear if the change was effective, because the outcome was already improving, and continued to improve after the change. Yearly data, used alone, could lead to an overestimation of the effectiveness of the change. Clinics in Perinatology 2010 37, 87-99DOI: (10.1016/j.clp.2010.01.005) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 4 To construct an annotated run chart, plot the date on the x-axis and the measurement on the y-axis. When changes are implemented, annotate the chart to enable a temporal link between changes and measurement. Clinics in Perinatology 2010 37, 87-99DOI: (10.1016/j.clp.2010.01.005) Copyright © 2010 Elsevier Inc. Terms and Conditions

Fig. 5 The Pareto chart is used to evaluate the relative contribution of various causes for a problem. Quality improvement efforts can then be focused on the “vital few” causes of the problem, without wasting energy and resources on the “trivial many” causes. Clinics in Perinatology 2010 37, 87-99DOI: (10.1016/j.clp.2010.01.005) Copyright © 2010 Elsevier Inc. Terms and Conditions