Purpose
The purpose of this document is to outline the steps for data collection, aggregation, charting, and submitting aggregate data to ACR for the Mammography Health Equity's collaborative measure using the control chart template.
Preparation
- Download the LN Mammo Health Equity Control Chart Template (1)
- 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
The following Excel worksheets are included within the template.
Setup Data Summary I Chart and P Chart
Setup
On the Setup worksheet you will select the collaborative you are participating in by using the drop down in cell B2 and enter your organization's name in cells B3.
Eligible population data is entered into cells B5-B8. You can select the population of patients served by using the drop down in cell B9.
NOTE: In cells B5-B8, enter the measure denominator source and value defined for your project. Example sources include: EMR, Market Share, Zipcode, and Total Imaging Volume. If your source is not listed, you can edit the text in cells A5 - A8. Sample numbers are pre-populated for reference. Please do not use these numbers for these numbers may not reflect the correct denominator values for your project.
Data Summary
The Data Summary worksheet is where you enter your weekly aggregate volume data for new and annual returning patient screenings. You do not need to enter a value for Total patients served. This is a calculated field, summing the weekly values in columns B and C.
NOTE: The data is aggregated weekly, Sunday to Saturday. For example, if you reviewed an exam with procedure date of Friday January 10, 2025 it will be aggregated under Date Sunday 05-Jan-25.
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 below to add future dates and extend the x-axis on your I and P Chart.
Select your eligible population. You can select your eligible population denominator by using the drop down in cell J2. Weekly eligible population values are calculated from the eligible population numbers entered on the Setup tab.
How to send weekly aggregate data to ACR, click on the weekly hyperlink in column E.
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.
I Chart
The I chart is used to visualize the weekly screening volumes. On the I Chart worksheet you will label, designate mean groupings and target values, and annotate your control chart. No exam data is entered on the I Chart worksheet.
New patient exam volume is indicated in grey, returning patient exam volume is indicated in white, and total screening volume is indicated by the blue line connecting the blue data points. The upper and lower control limits help you identify special cause variation points that warrant investigation.
P Chart
The P chart is used to visualize the percentage of eligible population being screened. 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.
The percentage of the weekly eligible population is indicated by the blue line connecting the blue data points and the grey bars indicate the weekly eligible population volume. The upper and lower control limits help you identify special cause variation points that warrant investigation.
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 I 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 I chart.
NOTE: Control limits will only appear for the ranges identified in the Mean Groupings section.
How to add target date and value: Enter the target value specified in your SMART goal on row 14 in the Target Date and Value section. The target line will be graphed on the P chart starting at the stated start date, cell B14, through the stated end date, cell C14.
NOTE: The End Date for both the I-chart and P-chart is entered in the I-chart Target Data and Value section.
How to add annotations: To add annotations to your I 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 I chart for the defined date.
