Purpose
The purpose of this document is to outline the steps for data collection, aggregation, charting, and submitting aggregate data to ACR for the Prostate MR Image Quality's collaborative measure using control chart template.
Preparation
- Download the LN Prostate Control Chart Template (12.27.2023)
- Save the template to your shared drive or upload to your organization's Microsoft 365 cloud. This could be either a One drive, Teams space, or SharePoint location for your project.
NOTE: You need a version of Excel later than Excel 2019 to support the template. If you use Excel 2016 or 2019, you will encounter a XLOOKUP error.
Overview
For the Prostate MR Image Quality Improvement Collaborative we will use the following Excel worksheets within the template.
Setup Form1 Data Summary P Chart
Technologist Performance Evaluator Performance
Setup
On the Setup worksheet you will select the collaborative you are participating in using the drop down in cell B2, and enter your organization's name in cell B3.
Form 1
Data may be collected using a customizable Image Audit Form. For more information, please see our article on How to Customize the Exam Image Audit Form.
In an open row on the Form1 tab, paste the values from the Microsoft audit form. To paste values, highlight an open row, right click, and select Values.
Data Summary
The Data Summary worksheet is where you enter your weekly aggregate volume data for exams meeting PI-QUAL criteria, DWI criteria and the number of exams reviewed in columns B, C, and D appropriately. You do not need to enter a value for % Met. This is a calculated field, based on your the weekly values in columns B, C, and C.
NOTE: The data is aggregated weekly, Sunday to Saturday. For example, if you reviewed an exam with procedure date of Friday June 3, it will be aggregated under Date 5/29.
Use Paste Values when copy-and-pasting data into the table. You do not need to paste future dates into the table. Please see directions above to add future dates and extend the x-axis of your P Chart.
How to send weekly aggregate data to ACR, click on the weekly hyperlink in column G. A prepopulated Smartsheet form will appear. Select the Submit button. No additional data entry is required to submit the form.
If edits are made to your weekly aggregate data, you can use the same hyperlink to re-submit the updated data.
P Chart
For the Prostate MR Image Quality Improvement Collaborative measure, we will use the P chart to visualize the weekly exam review data results: PI-QUAL and DWI. The charting template includes tabs for each of these measures:
On the P Chart worksheet you will label, designate mean groupings and target values, and annotate your control chart. No exam data is entered on the P Chart worksheet.
How to add a chart title and label chart axes: Input your chart title, left axis title, horizontal axis title, and right axis title in the fields within the Chart Title and Axes section appropriately. The titles will automatically appear on the P chart.
How to group data means: Enter the start and end date for your baseline data in row 8 columns B and C appropriately in the Mean Groupings section. When a shift in your data is confirmed, you can group a second or third mean by entering the appropriate start and end date for these ranges in rows 9 and 10 appropriately. Based on the start and end dates, the mean and control limits will be graphed on the P chart.
NOTE: Control limits will only appear for the ranges identified in the Mean Groupings section.
How to add target dates and value: Enter the end date and target value specified in your SMART goal on row 14 in the Smart Goal Date and Value section. The target line will be graphed on the P chart between the stated start date in cell B14 and end date stated in cell C15. You only need to enter the SMART goal end date on the PiQual P Chart tab - the same end date will automatically populate on the DWI P chart tab.
How to add annotations: To add annotations to your P chart, enter the date for a data point that need annotation using the dropdown menu in column A in the Annotations section. Enter the annotation in column B. The annotation will appear on your P chart for the defined date.
Technologist Performance
The Technologist Performance worksheet contains a dashboard displaying the PI-QUAL exam review results of each technologist. No exam data is entered on the Technologist Performance worksheet.
Evaluator Performance
The Evaluator Performance worksheet contains a dashboard displaying the PI-QUAL exam review results of each evaluator. No exam data is entered on the Evaluator Performance worksheet.