Improvement in Health Care: A Guide to Statistical Process Control.

Carey RG, Lloyd RC. New York, NY 10010, Quality Resources, 1995, hardback, 194 pp, $24.95:

Working with the concepts put forth by continuous quality improvement (CQI) theorists Walter A Shewhart and W Edwards Deming, the authors have written a book directed at the health care industry. Although numerous texts exist on total quality management (TQM) and CQI for the manufacturing industry utilizing the application of statistical process control (SPC), to my knowledge, this book is the first for health care systems.

Historically, health care professionals have been involved with quality assurance. This concept is flawed because action is taken only when a threshold of unacceptable quality has been exceeded. Therefore, complacency sets in when that unacceptable threshold has not been reached, and the quality of work suffers. Quality improvement is a more desirable approach that draws attention to the entire process. This approach is more consistent with the concept of TQM and with Deming's "never-ending cycle of continuous improvement."

The authors, however, do not discuss in any depth Deming's theories or the development, facilitation, or management of CQI teams. Their goal is to educate health care professionals on how to apply SPC tools to measure quality improvement, as opposed to the more commonly used anecdotal, quasi-scientific approach.

The text is organized into eight chapters, enhanced by flowcharts, and supported by a surprisingly brief list of references. Chapter 1 defines quality and the "CQI Journey." Through the use of a flowchart, the reader is carefully walked down the path from identifying an opportunity for improvement to standardizing the process, identifying quality characteristics (QC), defining the key quality characteristic (KQC), collecting and plotting data, identifying and selecting key process variables, analyzing the result, and identifying additional opportunities. This road map is the foundation for measuring the impact of action on a QC using SPC.

Chapters 2 and 3 discuss data generation and analysis, chapter 4 describes variation, and chapter 5 summarizes basic control chart theory. Chapter 6 is the largest section of the book. It contains 12 case studies designed to demonstrate how to successfully use the teachings of the preceding chapters. One case study is devoted to physical therapy. This study tracks the appropriate amount of therapy for patients with total hip or knee replacements. Though scientific in its approach, the authors do concede that a "liberal dose of common sense and subject knowledge" is needed. The final chapter is a departure from the basic teachings of the text and describes the use of patient surveys for CQI.

This book is a serious presentation. It is a difficult read because of the subject matter and not because of the authors' style. It is, however, understandable that a physical therapy practitioner unaccustomed to statistical design and flowcharting may need to reread sections to fully comprehend the material. This is a must read for anyone concerned with measuring outcomes and promoting quality improvement in the health care arena.

Mitchell Tannenbaum, PT NovaCare Outpatient Rehabilitation Division Lisle, IL

Mr Tannenbaum is the Divisional Assistant Vice President of Operations at NovaCare Outpatient Rehabilitation Division.