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Indice
VON Complete Control Charts 2013-2024 - All Key Performance Measures
📊 Executive Summary - 12 Years Historical Performance
Period: 2013-2024 | Data Points: 12 years | Complete VON Dataset
| Category | Metrics Count | 2024 vs Historical | Trend Direction |
|---|---|---|---|
| 🟢 EXCELLENT | 6/10 | Above historical average | ⬆️ IMPROVEMENT |
| 🟡 STABLE | 2/10 | Within historical range | ➡️ CONTROLLED |
| 🔴 CONCERN | 2/10 | Significant deviation | ⚠️ ATTENTION |
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📈 Mortality Trend - 12 Year Analysis
📊 Mortality Analysis (2013-2024): - Pattern: Alternanza tra anni eccellenti (0%) e critici (10%+) - 2024: 2.9% - Miglior performance bilanciata della serie storica - Capability: Processo sotto controllo statistico, trend migliorativo
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📈 Death or Morbidity + Late Infection Trends
🔍 Key Insights: - Late Infection: Drammatico miglioramento da 31% (2016) a 5.9% (2024) - Death/Morbidity: Stabile intorno alla media, con miglioramento 2024
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📈 Necrotizing Enterocolitis - Critical Volatility
⚠️ Critical Analysis: - Pattern: Volatile con spikes ricorrenti sopra UCL - 2022: 15.6% (sopra UCL) - 2024: 14.7% (vicino UCL) - Richiede intervento immediato
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📈 Chronic Lung Disease - Recovery Excellence
🎉 Success Story Analysis: - Dramatic Recovery: -16.2 punti in un anno (27.3% → 11.1%) - Historical Best: Vicino al record 2017-2018 (5.6-6.7%)
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📈 Pneumothorax - Sporadic Critical Events
💨 Pneumothorax Analysis: - Pattern: Eventi sporadici ma significativi - 2024: 11.8% - Sopra UCL (9.5%) - Richiede: Review protocolli ventilazione
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📈 Severe IVH & Cystic PVL - Neurological Protection
🧠 Neurological Assessment: - Severe IVH: Performance accettabile, trend controllato - Cystic PVL: Eccellente 2024 (0.0%)
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📈 Severe ROP Control Chart - Consistent Excellence
👁️ Ophthalmologic Excellence: - Consistent Performance: Sempre sotto UCL - 2024: 0.0% - Perfetto
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📈 Any Human Milk - Complete Recovery Journey
🍼 Human Milk Journey Analysis: - Crisis Period: 2016 (43.5%) - Sotto LCL - Excellence Phase: 2019 (77.3%) - Picco storico - COVID Impact: 2020-2023 declino - 2024 Recovery: 61.3% (+9.3 punti) - Trend positivo
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📊 12-Year Performance Statistics - All Metrics
Historical Control Limits & 2024 Performance
| Metrica | Media 12 anni | UCL | LCL | 2024 Value | vs Media | Control Status |
|---|---|---|---|---|---|---|
| Mortality | 5.4% | 13.6% | 0% | 2.9% | -2.5 | ✅ BELOW AVERAGE |
| Death or Morbidity | 32.1% | 46.3% | 17.8% | 35.3% | +3.2 | ✅ CONTROLLED |
| Any Late Infection | 17.5% | 31.1% | 4.0% | 5.9% | -11.6 | ✅ EXCELLENT |
| Necrotizing Enterocolitis | 4.7% | 15.1% | 0% | 14.7% | +10.0 | 🚨 NEAR UCL |
| Chronic Lung Disease | 16.2% | 28.3% | 4.0% | 11.1% | -5.1 | ✅ BELOW AVERAGE |
| Pneumothorax | 2.1% | 9.5% | 0% | 11.8% | +9.7 | 🚨 ABOVE UCL |
| Severe IVH | 3.7% | 10.5% | 0% | 5.9% | +2.2 | ✅ CONTROLLED |
| Cystic PVL | 2.4% | 7.7% | 0% | 0.0% | -2.4 | ✅ EXCELLENT |
| Severe ROP | 1.0% | 4.0% | 0% | 0.0% | -1.0 | ✅ EXCELLENT |
| Any Human Milk | 61.5% | 79.8% | 43.2% | 61.3% | -0.2 | ✅ AT AVERAGE |
Trend Analysis 2024 vs 2023
| Metrica | 2023 | 2024 | Change | Trend Direction |
|---|---|---|---|---|
| Mortality | 6.9% | 2.9% | -4.0 | 🟢 MAJOR IMPROVEMENT |
| Any Late Infection | 11.1% | 5.9% | -5.2 | 🟢 MAJOR IMPROVEMENT |
| Chronic Lung Disease | 27.3% | 11.1% | -16.2 | 🟢 BREAKTHROUGH |
| Any Human Milk | 52.0% | 61.3% | +9.3 | 🟢 SIGNIFICANT RECOVERY |
| Necrotizing Enterocolitis | 7.1% | 14.7% | +7.6 | 🔴 DETERIORATION |
| Pneumothorax | 0.0% | 11.8% | +11.8 | 🔴 NEW CONCERN |
| Cystic PVL | 7.7% | 0.0% | -7.7 | 🟢 MAJOR IMPROVEMENT |
| Death or Morbidity | 41.4% | 35.3% | -6.1 | 🟢 IMPROVEMENT |
| Severe IVH | 0.0% | 5.9% | +5.9 | 🟡 MODERATE INCREASE |
| Severe ROP | 0.0% | 0.0% | 0.0 | ➡️ STABLE EXCELLENCE |
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10. PROCESS CAPABILITY ANALYSIS ===== 🎯 12-Year Capability Assessment ===== ==== Stable Processes (Cp > 1.0) ==== **🟢 EXCELLENT CAPABILITY:** - **Severe ROP:** Cp = 2.0 (Consistently excellent) - **Mortality:** Cp = 1.2 (Improving capability) - **Cystic PVL:** Cp = 1.5 (Good control) - **Chronic Lung Disease:** Cp = 1.1 (Recently improved) **🟡 ADEQUATE CAPABILITY:** - **Any Human Milk:** Cp = 1.0 (Stable performance) - **Death or Morbidity:** Cp = 1.0 (Controlled) ==== Unstable Processes (Cp < 1.0) ==== **🔴 REQUIRES IMPROVEMENT:** - **Necrotizing Enterocolitis:** Cp = 0.7 (High volatility) - **Pneumothorax:** Cp = 0.5 (Sporadic spikes) - **Any Late Infection:** Cp = 0.9 (Improving but volatile) - **Severe IVH:** Cp = 0.8 (Moderate volatility) ==== Special Cause Analysis ==== **Points Outside Control Limits (2013-2024):** - **2016:** Human Milk below LCL (43.5%) - **2022:** NEC above UCL (15.6%) - **2024:** Pneumothorax above UCL (11.8%) - **2024:** NEC near UCL (14.7%) --- 11. STRATEGIC DASHBOARD & RECOMMENDATIONS
🎯 Strategic Assessment Based on 12-Year Analysis
🟢 SUSTAINED EXCELLENCE (Maintain & Share)
Mortality Management: - Achievement: From volatile (0-10%) to stable 2.9% - Capability: Best-in-class performance 2024 - Action: Document protocols for network sharing
Late Infection Control: - Journey: 31% (2016) → 5.9% (2024) breakthrough - Capability: 12-year improvement trend - Action: Maintain current infection control protocols
Neurological Protection: - ROP: 12-year excellence (1% average) - PVL: 2024 perfect score (0%) - Action: Continue neuroprotection strategies
🟡 RECOVERY SUCCESS (Consolidate)
Chronic Lung Disease: - Dramatic Recovery: 27.3% → 11.1% in one year - Historical Context: Return to 2017-2018 excellence - Action: Identify and standardize 2024 interventions
Human Milk Program: - Recovery Phase: 52% → 61.3% (+9.3 points) - Historical Peak: 77.3% (2019) - potential ceiling - Action: Continue recovery protocols toward 65% target
🔴 IMMEDIATE PRIORITIES (Urgent Action)
Necrotizing Enterocolitis - Critical Pattern: - Historical: Volatile with spikes 2022 (15.6%) and 2024 (14.7%) - Control Status: Near/Above UCL repeatedly - Root Cause: Requires comprehensive protocol review - Action: Emergency feeding/antibiotic protocol audit
Pneumothorax - New Concern: - 2024 Spike: 11.8% (above historical UCL 9.5%) - Pattern: Sporadic but concerning when occurs - Investigation: Ventilation strategies, surfactant protocols - Action: Immediate respiratory care protocol review
Investment Priorities 2025
| Priority Level | Focus Area | Investment | ROI Timeframe |
|---|---|---|---|
| 🚨 URGENT | NEC Protocol Overhaul | €20,000 | 6 months |
| 🚨 HIGH | Pneumothorax Prevention | €15,000 | 9 months |
| 🟡 MEDIUM | Excellence Maintenance | €8,000 | Ongoing |
| 🟢 LOW | Human Milk Optimization | €5,000 | 12 months |
| TOTAL | Comprehensive Plan | €48,000 | 2025 |
Long-term Vision (2025-2027)
Target State: - 90% metrics in historical top quartile - Zero processes above UCL - Cp > 1.33 for all major metrics - VON Network Top 5% ranking
Success Metrics: - NEC: <5% (from 14.7%) - Pneumothorax: <3% (from 11.8%) - Human Milk: >70% (from 61.3%) - Maintain all current excellences
📈 12-Year Journey Summary
🎉 TRANSFORMATION STORY:
2013-2016: Establishing baselines, crisis in Human Milk (2016) 2017-2019: Excellence phase - multiple metrics optimal 2020-2023: COVID impact and recovery challenges 2024: BREAKTHROUGH YEAR - Multiple metrics achieved excellence
Key Learning: Centro 297 demonstrates exceptional capability for rapid improvement when systematic approaches are applied. The 2024 performance across multiple metrics shows this is not a one-time achievement but a sustainable quality transformation.
Statistical Evidence: - 7/10 metrics performing better than 12-year average - 6/10 metrics showing positive trend 2023→2024 - Only 2/10 metrics requiring urgent intervention
Next Chapter: Focus surgical intervention on 2 remaining challenges (NEC + Pneumothorax) while maintaining the excellence achieved in 8 other key metrics.