title: Cumulative summation (CUSUM) charts in the monitoring of hypospadias outcomes: a tool for quality improvement initiative.
abstract: OBJECTIVE
  Cumulative summation (CUSUM) charting is a statistical tool that allows an individual surgeon or surgical department to monitor any binary outcome and rapidly detect when complications are outside the acceptable limits. We applied CUSUM statistical analysis to hypospadias repair to utilize the results in our own quality Improvement process.
  
  
  METHODS
  An institutional review board-approved retrospective review of all patients who underwent hypospadias repair by a single fellowship trained pediatric urologist at a single institution between September 2004 to July 2009 was performed. To graphically represent the complication rates and to assess for unacceptable rates, the use of CUSUM control charting was employed.
  
  
  RESULTS
  In our retrospective review, there were a total of 184 patients who underwent a total of 203 surgeries. Using CUSUM analysis, our incidence of major complications was within acceptable limits until approximately the first 150 operations had been performed, at which time the complication rate fell below the lower limit, indicating performance exceeded expectations.
  
  
  CONCLUSIONS
  CUSUM statistical charting was successfully applied to the retrospective monitoring of hypospadias outcomes at our institution. This is the first known publication in which CUSUM charts were used to evaluate complications of hypospadias repair.
authors.affiliation: Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Parikh
authors.affiliation: Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA. Electronic address: apark@temple.edu.
authors.forename: A M
authors.initials: AM
authors.lastname: Park
authors.affiliation: Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA.
authors.forename: J
authors.initials: J
authors.lastname: Sumfest
mesh_terms: D002675:Child, Preschool; D015331:Cohort Studies; D006801:Humans; D007021:Hypospadias / Q000175:diagnosis / Q000601:surgery*; D007223:Infant; D008297:Male; D008499:Medical Records; D008991:Monitoring, Physiologic / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D011379:Prognosis; D058996:Quality Improvement; D012189:Retrospective Studies; D013529:Surgical Wound Dehiscence / Q000175:diagnosis / Q000453:epidemiology; D016896:Treatment Outcome; D014521:Urethra / Q000601:surgery*; D014525:Urethral Stricture / Q000175:diagnosis / Q000453:epidemiology; D013520:Urologic Surgical Procedures / Q000009:adverse effects* / Q000379:methods
keywords: CUSUM; Complications; Cumulative summation; Hypospadias; Hypospadias repair