Quality Analysis and Management

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Quality Analysis and Management


Upon completion of this activity, the student should be able to:

  • Retrieve requested patient data from a departmental database.
  • Calculate mortality/autopsy rates for a specific time period.
  • Communicate statistical findings required for a specific request

Definitions for the Assignment

Medical Patient is a patient who has no procedure code listed in the Principal Procedure column or has a minor diagnostic or therapeutic procedure (codes 87.0-99.99) listed in the Principal Procedure Column.

Surgical Patient is a patient with a Surgical Procedure code listed in the Principal Procedure column (excluding principal procedures which are minor diagnostic procedures – codes 87.0 to 99.99).


Dr. Fox, the Chief of Surgery for Community Hospital, wishes to study the records of patients during the past six months who died within two days of surgery. He is not interested in patients who had minor procedures done (diagnostic or therapeutic), only those who had major surgical procedures. He is particularly interested in the records of those patients who did not have an autopsy performed and would like to know the surgeon involved. 

Download and review the Community Hospital Death Register from July 1, 20XX through December 31, 20XX.

  1. Using Microsoft Word, prepare a table for Dr. Fox that includes surgical patients who expired within two days of surgery. In the table, include each patient’s medical record number, age, sex, final diagnosis code, principal procedure code and whether or not the patient had an autopsy. 
  1. Generate a list of records, from the table you created in #1, to be pulled for Dr. Fox, so that he can review the records of patients who died within two days of surgery, but did NOT have an autopsy.
  1. Compute the following mortality and autopsy statistics to include in the memo to Dr. Fox: 
    1. Percentage of total deaths that were surgical (NOTE: surgical deaths do not include those with minor procedures as described in the Definitions above.)
    2. Percentage of surgical deaths that died within 2 days of surgery 
    3. Autopsy rate for surgical deaths within two days of surgery
  1. Write a memo to Dr. Fox that includes all the requested information. Include any other data that you think he may find helpful or interesting.


This activity will be evaluated for:

  • The ability to retrieve the requested data from the death register.
  • Correctly computing the statistics.
  • Documenting the findings in memo format.

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