Patient Puzzlers for Healthcare

Out-of-Control patient collections

Ms. Collette D’Bills, patient accounting, has gathered data related to accounts receivable, entering it to an Excel spreadsheet. In fact, she has several years’ worth of data in her Excel files, but has not been able to understand what it means, except to see that accounts receivable sometimes go up and sometimes go down. At the end of the year, she usually files the spreadsheets along with earlier records and gives them no further thought.

Her new assistant, Anne A. Lytical, is appalled at this waste. "Why, if you had charted this data, you’d be able to see trends," she exclaimed. Collette points out that she has seen trends. "Sometimes receivables are up, sometimes they’re down." That was enough of a trend to suit her.

Anne, however, uses CHARTrunner to chart the Excel data, and within minutes she brings Collette the following chart.

At the seminar, Dr. Noah Tahl explains the meaning of "in-control" and "out-of-control," and picks up Collette’s chart to examine it. "Your accounts receivable process is definitely out of control," he says, as his finger follows the downward trend of the data. "You’ve got to get this process back under control!"

"But," says Colette, "we’ve made so much improvement, how can it be a bad thing that the data is out of control?" She sends follow-up letters to all customers three weeks after they have been billed; if there is not response, Colette has then made an additional phone call. But true to his name, Dr. Noah Tahl insists that his job is to bring processes into control, and since hers is definitely not, it must be changed.

Who is right?

A. Dr. Noah Tahl

B. Ms. Collette D'Bills

The correct answer is B.

Sometimes language can get in the way of real understanding. The term "out of control" is easily misunderstood as a pejorative term, suggesting that something is wrong. Other language, such as "stable" vs. "unstable;" "consistent" vs. "inconsistent" or "predictable vs. unpredictable" would convey more clearly the fact that the pattern that Ms. D'Bills sees in her data is not bad, since a state of being out of control can in fact be a good thing. 

Dr. Noah Tahl is correct in asserting that this chart represents an out-of-control situation. On March 2, a run below the mean begins, and continues for 8 consecutive months. In January, there is even a point beyond the lower control limit. But in this case, the value of what is being measured changes the interpretation of the chart. One would want the accounts receivable to go down rather than remain stable, since this trend indicates an expanding (not diminishing) collection rate for the hospital. 

So while Dr. Tahl recognizes the textbook pattern here, Ms. D'Bills' intuitive sense that the data represents a positive development is in fact a more accurate interpretation of the pattern.