Data Analysis and Quality Improvement Initiative Proposal
!""#""$#%&'()'*+&+'!%+,-"."'+%/'01+,.&-'2$3456#$#%& 2%.&.+&.6#'74535"+,
!""#$%"&'&()*&+##,&#-)./)"#0
!"#$%&&"'()
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
>&#./0#4(-%#'+(,?%&G(99"7"/,/#./02#,%A7#&034"&&"/,)#<:%(&%#3%#&02%#7/#+"?+:"?+7#H/2#0&%#2%9#1/,7I#7/#,/7%#7+%#'+(,?%&G(99"7"/,(9%5#*+"& +%:<&#,(22/8#7+%#2%J%;(:0(7"/,#7/#7+/&%#(2%(+(7#+(;%#3%%,#2%;"&%95
*+(,-&)
K25#K.-%&
! !"#$%"&!'(")*'+,&%)&-+!'&..+../+$-'01%+
2"/3+-+$2('4
1.),&2/).3"4&3$%56-#$#,"&3,3"3)"3-#*&3,&5#*%6,*#&"6&)0-#5*#&#-#,"*&),0&,#)57$3**&),).4*#*8
96/5&5#*/.":&56789
K"&7",?0"&+%9
K%7%24",%+%7+%2#(,.#(9;%2&%
%;%,7#/2#,%(2J4"&	(7(#40&7#3%
1('7/2%9#",#7/#/07'/4%&#(,9
2%'/44%,9(7"/,&5#E<%'"1"%+%
'2"7%2"(#3.#8+"'+#7+%
9%7%24",(7"/,#"(9%5
L2/1"'"%,7
K%7%24",%+%7+%2#(,.#(9;%2&%
%;%,7#/2#,%(2J4"&	(7(#40&7#3%
1('7/2%9#",#7/#/07'/4%&#(,9
2%'/44%,9(7"/,&5
56789
&::;<=:7':>'?;:;@<8A;
BC;:C;@'6AD'6?E;@7;';E;A:'>@
A;6@F<877'?6:6'<G7:'H;
I69:>@;?'8A':>'>G:9><;7'6A?
@;9><<;A?6:8>A7J'C>B;E;@K
><8778>A7'6A?L>@';@@>@7';M87:N
M/,JL%21/24(,'%
K/%&#,/7#9%7%24",%#8+%7+%2#(,.
(9;%2&%#%;%,7#/2#,%(2J4"&	(7(
40&7#3%#1('7/2%9#",#7/#/07'/4%&
(,9#2%'/44%,9(7"/,&5
;)</."4&=6$$#,"*:
>&#./0#(2%#9%;%:/<",?#./02#&<%'"1"'#2%'/44%,9(7"/,&)#9"&'0&&#+/8#(,.#&<%'"1"'#(9;%2&%#%;%,7#/2#(9;%2&%#%;%,7#9(7(#"%:(7%9#7/#7+/&% 2%'/44%,9(7"/,&5
2"/3+-+$2('O
1.),&2/).3"4&3$%56-#$#,"&3,3"3)"3-#*&3,&5#*%6,*#&"6&56/"3,#&0)")&*/5-#3..),<#8
96/5&5#*/.":&56789
K"&7",?0"&+%9
K%;%:/<&#(#=6#","7"(7";%#<2/</&(:
3(&%9#/,#(#&%:%'7%9#+%(:7+#"&&0%
(,9#&0<</27",?#9(7(#(,(:.&"&5
L2/</&(:#"9%,7"1"%&#-,/8:%9?%
?(<&)#0,-,/8,&)#4"&&",?
",1/24(7"/,)#0,(,&8%2%9
F0%&7"/,&)#/2#(2%(&#/1
0,'%27(",7.#8+%2%#1027+%2
",1/24(7"/,#'/0:9#"4<2/;%#7+%
<2/</&(:5
L2/1"'"%,7
K%;%:/<&#(#=6#","7"(7";%#<2/</&(:
3(&%9#/,#(#&%:%'7%9#+%(:7+#"&&0%
(,9#&0<</27",?#9(7(#(,(:.&"&5
56789
&::;<=:7':>'?;E;P>='6'Q1
8A8:86:8E;'=@>=>76PK'HG:
=@>=>76P'87'<8778AR
H;A9C<6@S7K'87'A>:';E8?;A9;F
H67;?K'87'8<=@69:896PK'>@'87'A>:
9P;6@PD'P8AS;?':>':C;'7;P;9:;?
C;6P:C'877G;'>@'7G==>@:8AR'?6:6
6A6PD787N
M/,JL%21/24(,'%
K/%&#,/7#9%;%:/<#(#=6#","7"(7";%
<2/</&(:#3(&%9#/,#(#&%:%'7%9
+%(:7+#"&&0%#(,9#&0<</27",?#9(7(
(,(:.&"&5
;)</."4&=6$$#,"*:
B/0#+(;%#(#8/,9%210:#7+%/2%7"'(:#1/0,9(7"/,#1/2#7+%#'+(,?%#<2/'%&ij#8%#(2%#4"&&",?#7+%#('70(:#'/4</,%,7&#/1#7+%#<2/</&(:5#>&#./0#://-#(7#7+% +%(:7+#'(2%#"&&0%)#8+(7#&<%'"1"'#2%'/44%,9(7"/,/0:9#./0#4(-%#1/2#7+%#@":(#!%(:7+#!/&<"'%#7/#+%:<#"4<2/;%#7+%#<(7"%,7#'(2%#"&&0%N
2"/3+-+$2('T
>-)./)"#&2/).3"4&3$%56-#$#,"&3,3"3)"3-#*&/*3,?&*#,*3"3-#&),0&*6/,0&6/"<6$#&$#)*/5#*8
96/5&5#*/.":&3@>I898;A:
K"&7",?0"&+%9
>,(:.O%	(7(#7/#"9%,7"1.#(
+%(:7+#'(2%#"&&0%#/2#(2%(#/1
'/,'%2,P#%;(:0(7%	(7(#F0(:"7.5
3@>I898;A:
&A6PDU;7'?6:6':>'8?;A:8ID'6
C;6P:C'96@;'877G;'>@'6@;6'>I
9>A9;@AN
Q(&"'
>77%4<7/#(,(:.O%#9(7()#307
4"&&%H%,9&#/2#/<</270,"7"%&
1/2#F0(:"7.#"4<2/;%4%,7)#/2#9/%&
,/7#<%2&0(&";%:.#:",-#9(7(#7/#(
+%(:7+#'(2%#"&&0%#/2#(2%(#/1
'/,'%2,5
M/,JL%21/24(,'%
K/%&#,/7#(,(:.O%#9(7(#7/#"9%,7"1.
(#+%(:7+#'(2%#"&&0%#/2#(2%(#/1
'/,'%2,5
;)</."4&=6$$#,"*:
B/0#9/#(#?2%(7#D/3#/1#(,(:.O",?#7+%#9(7(#/1#@":(#!%(:7+#7/#9%7%24",%#7+%#+%(:7+#'(2%#'/,'%2,#2%:(7%9#7/#7+%#F0(:"7.#/1#'(2%#",#7+%#+/&<"'%#&%77",?5 */#4(-%#7+"&#(2%(#9"&7",?0"&+%9)#&0<</27#7+"&#(2%(#/1#'/,'%2,#8"7+#/07&"9%)#&'+/:(2:.#&/02'%/#2%",1/2'%#7+%#"4</27(,'%#/1#<(",#'/,72/:#(,9 '/41/27#4%(&02%&#",#7+%#+/&<"'%#&%77",?5#*+"&#&0<</27+%#F0(:"7.#/1#7+%#9(7(5
2"/3+-+$2('V
@,"#?5)"#&3,"#5%56A#**36,).&%#5*%#<"3-#*&"6&.#)0&2/).3"4&3$%56-#$#,"*&3,&%)"3#,"&*)A#"4B <6*"&#AA#<"3-#,#**B&),0&C65D&.3A#&2/).3"48
96/5&5#*/.":&56789
K"&7",?0"&+%9
R/440,"'(7%&#=6#","7"(7";%
<2/</&(:)#3(&%9#/,
",7%29"&'"<:",(2.#7%(4#",<07)#7/
"4<2/;%#<(7"%,7#&(1%7.#(,9
F0(:"7.#/07'/4%&#(,9#8/2-J:"1%
F0(:"7.5#69%,7"1"%&#(&&04<7"/,&#/,
8+"'+#7+%#",<07&#(2%#3(&%95
L2/1"'"%,7
R/440,"'(7%&#=6#","7"(7";%
<2/</&(:)#3(&%9#/,
",7%29"&'"<:",(2.#7%(4#",<07)#7/
"4<2/;%#<(7"%,7#&(1%7.#(,9
F0(:"7.#/07'/4%&#(,9#8/2-J:"1%
F0(:"7.5
56789
&::;<=:7':>'9><<GA896:;'Q1
8A8:86:8E;'=@>=>76PK'H67;?'>A
8A:;@?8798=P8A6@D':;6<'8A=G:K
HG:'<877;7'@;P;E6A:'@>P;7'>@
9>A9;=:7'@;P6:;?':>'=6:8;A:
76I;:D'6A?'WG6P8:D'>G:9><;7
6A?'B>@SFP8I;'WG6P8:DN
M/,JL%21/24(,'%
K/%&#,/7#'/440,"'(7%#=6
","7"(7";%#<2/</&(:)#3(&%9#/,
",7%29"&'"<:",(2.#7%(4#",<07)#7/
"4<2/;%#<(7"%,7#&(1%7.#(,9
F0(:"7.#/07'/4%&#(,9#8/2-J:"1%
F0(:"7.5
;)</."4&=6$$#,"*:
B/02#9"&'0&&"/,#/1#7+%#"4</27(,'%#/1#",7%29"&'"<:",(2.#7%(4#'/440,"'(7"/,#(,9#",<07#"%::#9/,%)#+/8%;%2)#&",'%#./0#9/,S7#+(;%#&<%'"1"' 2%'/44%,9(7"/,/2#7+%#=66#<2/</&(:)#./0#&03&%F0%,7:.#9/#,/7#+(;%#+/8#7+"&#",<07#(11%'7%9#./02#9%;%:/<4%,7#/1#2%'/44%,9(7"/,&5#>&#./0 9%;%:/<#./02#2%'/44%,9(7"/,&)#:",-#7+%#",7%29"&'"<:",(2.#1%%93('-#7+(7#./0#8%2%#<2/;"9%9#",#7+%#&'%,(2"/5
2"/3+-+$2('X
!%%.4&#AA#<"3-#&<6$$/,3<)"36,&*"5)"#?3#*&"6&%56$6"#&2/).3"4&3$%56-#$#,"&6A 3,"#5%56A#**36,).&<)5#8
96/5&5#*/.":&3@>I898;A:
K"&7",?0"&+%9
*+/2/0?+:.#",7%?2(7%%:%;(,7
&/02'%/#&0<</27#(2?04%,7&
0&",?#%22/2J12%%#>L>#&7.:%#(,9
1/24(77",?#",#'"7(7"/,&#(,9
2%1%2%,'%&5
3@>I898;A:
1A:;R@6:;7'@;P;E6A:'7>G@9;7':>
7G==>@:'6@RG<;A:7K'9>@@;9:PD
I>@<6::8AR'98:6:8>A7'6A?
@;I;@;A9;7'G78AR'&3&'7:DP;N
Q(&"'
6,7%?2(7%&#"22%:%;(,7#&/02'%&)
",7%?2(7%&#&/02'%&#",%11%'7";%:.)
/2#1/24(7&#'"7(7"/,&#(,9
2%1%2%,'%"7+#%22/2&#",#>L>
&7.:%5
M/,JL%21/24(,'%
K/%&#,/7#",7%?2(7%#2%:%;(,7
&/02'%/#&0<</27#(2?04%,7&)
'/22%'7:.#1/24(77",?#'"7(7"/,&#(,9
2%1%2%,'%�&",?#>L>#&7.:%5
;)</."4&=6$$#,"*:
C"7+#7+%#'022%,7#'/,7%,7)#./0#+(;%#",7%?2(7%9#2%:%;(,7#&/02'%/#&0<</27#./02#(2?04%,7&5#B/0#+(;%#'/22%'7:.#1/24(77%9#7+%#'"7(7"/,&#(,9 2%1%2%,'%�&",?#>L>#&7.:%5#T,'%#./0#(2%#(3:%#7/#(99#",#./02#2%'/44%,9(7"/,&#(,9#0&%#&'+/:(2:.#'"7(7"/,/#&0<</27#7+%4)#7+"&#(2%(#8"::#%(&":. 3%'/4%#9"&7",?0"&+%95
96/5&5#*/.":&56789
K"&7",?0"&+%9
K%7%24",%(:7"<:%#%;"9%,'%J
3(&%9#'/440,"'(7"/,#&72(7%?"%&
7/#<2/4/7%#F0(:"7.#"4<2/;%4%,7
/1#",7%2<2/1%&&"/,(:#'(2%5
L2/1"'"%,7
K%7%24",%&#'/440,"'(7"/,
&72(7%?"%/#<2/4/7%#F0(:"7.
"4<2/;%4%,7#/1
",7%2<2/1%&&"/,(:#'(2%5
56789
&::;<=:7':>'?;:;@<8A;
9><<GA896:8>A'7:@6:;R8;7':>
=@><>:;'WG6P8:D'8<=@>E;<;A:
>I'8A:;@=@>I;778>A6P'96@;K'HG:
7:@6:;R8;7'6@;'P8<8:;?'6A?L>@
A>:';E8?;A9;FH67;?N
M/,JL%21/24(,'%
K/%&#,/7#9%7%24",%
'/440,"'(7"/,#&72(7%?"%/
<2/4/7%#F0(:"7.#"4<2/;%4%,7#/1
",7%2<2/1%&&"/,(:#'(2%5
;)</."4&=6$$#,"*:
B/02#&%'7"/,#/,#'/440,"'(7"/,#&72(7%?"%&#"%::#9/,%#8"7+#2%?(29#7/#7+%#"4</27(,'%#/1#'/440,"'(7"/,5#L:%(&%#(99#(7#:%(&7#78/#&<%'"1"' '/440,"'(7"/,#&72(7%?"%+(7#'(,#3%#0&%9#7/#<2/4/7%#",7%2<2/1%&&"/,(:#'(2%5
*/#4(-%#7+%#(2%(#9"&7",?0"&+%9)#./0#8/0:9#8(,7#7/#'"7%#&'+/:(2:.#&/02'%/#4(-%#./02#&0??%&7%9#&72(7%?"%&#%;"9%,'%J3(&%95
96/5&5#*/.":&56789
K"&7",?0"&+%9
R/440,"'(7%&#=6#","7"(7";%
<2/</&(:#",#(#<2/1%&&"/,(:)
%11%'7";%#4(,,%2)#82"7",?#'/,7%,7
':%(2:.#(,9#:/?"'(::.)#8"7+#%22/2J
12%%#0&%#/1#?2(44(2)
<0,'70(7"/,)#(,9#&<%::",?5
L2/</&(:#",':09%(:7"<:%
&<%'"1"'&)#%A(4<:%&)#(,9
2%1%2%,'%/#'022%,7#&'+/:(2:.
(,9G/2#(07+/2"7(7";%#&/02'%&5
L2/1"'"%,7
R/440,"'(7%&#=6#","7"(7";%
<2/</&(:#",#(#<2/1%&&"/,(:)
%11%'7";%#4(,,%2)#82"7",?#'/,7%,7
':%(2:.#(,9#:/?"'(::.)#8"7+#'/22%'7
0&%#/1#?2(44(2)#<0,'70(7"/,)
(,9#&<%::",?5
56789
&::;<=:7':>'9><<GA896:;'Q1
8A8:86:8E;'=@>=>76P'8A'6
=@>I;778>A6PK';II;9:8E;'<6AA;@K
HG:'P6=7;7K'><8778>A7K'6A?L>@
;@@>@7'?;:@69:'I@><':C;'>E;@6PP
<;776R;N
M/,JL%21/24(,'%
K/%&#,/7#'/440,"'(7%#=6
","7"(7";%#<2/</&(:#",#(
<2/1%&&"/,(:)#%11%'7";%#4(,,%2)
82"7",?#':%(2:.#(,9#:/?"'(::.)#8"7+
'/22%'7#0&%#/1#?2(44(2)
<0,'70(7"/,)#(,9#&<%::",?5
;)</."4&=6$$#,"*:
B/02#82"7",?#"&#%11%'7";%#(,9#<2/1%&&"/,(:5#B/02#0&%#/1#?2(44(2)#&<%::",?)#(,9#<0,'70(7"/,#"%::#9/,%#8"7+#40:7"<:%#&<%'"1"'&)#%A(4<:%&)#(,9 2%1%2%,'%&5#*+%#/,:.#2%(&/,#7+"&#'2"7%2"(#"&#,/7#9"&7",?0"&+%9#"%'(0&%#8%#(2%#('70(::.#4"&&",?#7+%#30:-#/1#7+%#&<%'"1"'#=66#<2/</&(: 2%'/44%,9(7"/,&5#T,'%#7+(7#"&#""A%9)#7+"&#(2%(#8"::#3%#(9D0&7%95
",+*&%%'2"//+$-.
2*1-+*1"$
!;:;@<8A;'BC;:C;@'6AD'6?E;@7;';E;A:'>@'A;6@F<877'?6:6'<G7:'H;'I69:>@;?'8A':>'>G:9><;7'6A?'@;9><<;A?6:8>A7N
2*1-+*1"$
!;E;P>='6'Q1'8A8:86:8E;'=@>=>76P'H67;?'>A'6'7;P;9:;?'C;6P:C'877G;'6A?'7G==>@:8AR'?6:6'6A6PD787N
2*1-+*1"$
&A6PDU;'?6:6':>'8?;A:8ID'6'C;6P:C'96@;'877G;'>@'6@;6'>I'9>A9;@AN
2*1-+*1"$
2><<GA896:;'Q1'8A8:86:8E;'=@>=>76PK'H67;?'>A'8A:;@?8798=P8A6@D':;6<'8A=G:K':>'8<=@>E;'=6:8;A:'76I;:D'6A?'WG6P8:D'>G:9><;7'6A?'B>@SFP8I;'WG6P8:DN
2*1-+*1"$
1A:;R@6:;'@;P;E6A:'7>G@9;7':>'7G==>@:'6@RG<;A:7K'9>@@;9:PD'I>@<6::8AR'98:6:8>A7'6A?'@;I;@;A9;7'G78AR'&3&'7:DP;N
2*1-+*1"$
!;:;@<8A;';E8?;A9;FH67;?'9><<GA896:8>A'7:@6:;R8;7':>'=@><>:;'WG6P8:D'8<=@>E;<;A:'>I'8A:;@=@>I;778>A6P'96@;N
2*1-+*1"$
2><<GA896:;'Q1'8A8:86:8E;'=@>=>76P'8A'6'=@>I;778>A6PK';II;9:8E;'<6AA;@K'B@8:8AR'9P;6@PD'6A?'P>R896PPDK'B8:C'9>@@;9:'G7;'>I'R@6<<6@K'=GA9:G6:8>AK'6A?'7=;PP8ARN
!+-&1%. &--+/3-'4 >-)./)"#0 &--+/3-'O !-)3.)+.# &--+/3-'T
!"#$%&'()*+,)-+". ! /+01&22&'345&% 67!89:;' !"#$% !
3).+&2'("$2+. !<7!= !
&'()*$* 89:;<8=9: >?'>9*2!
:#-"$+)2% >#??"$- 9",'<#- '@#"".A+'8+$5" ++