The Textbook of TQ in Healthcare.

The editors list two objectives for this book:

* Education of future health care workers.

* Reference book for those already in the field,

The editors/contributors achieved these objectives. This is a fine textbook, and, at the same time, it serves as a broad reference. To accomplish both of these objectives in a very readable fashion is a true accomplishment.

This textbook does use for some chapters, or parts of chapters, what I would term "unrecognized" contributors. By this I mean that reprints of original articles by various authors are utilized in the chapters. These contributors are not recognized in the Table of Contents or under Contributors. The articles themselves provide a very substantive element to the book as a whole.

Some deficiencies that I believe exist in the book include:

* There is redundancy in some chapters, a predictable outcome when a book has multiple authors. However, the redundancy or rework is not consistent with a textbook on quality or TQ, which probably should be a paragon of the absence of rework/redundancy. It occurs too frequently to be considered merely a matter of appropriate repetition for emphasis.

* Selection criteria for reprints of articles used in various chapters are not elucidated. Some of these chapters are considered "classics," but not all "classics" are represented. For example, Codman's original contributions are missing.

* The prime focus for TQ in this book is defined as the patient being the most important customer; however, TQ/TQM/CQI (whatever acronym one wishes to use) recognizes that there are other internal/external customers. They are generally ignored in this book, apparently intentionally. This could lead the neophyte to believe that the patient is the only focus for TQ. I think that this narrow focus misses the presentation of the totality of total quality management.

The chapter titles provide a view of the depth and breadth of this volume The following are brief summaries of each of the chapters:

Introduction and Historical Background - The historical overview is well done. It reviews regulatory and nonregulatory, governmental and nongovernmental focus on structure, process, and outcomes of health care as indicators of quality. It emphasizes the fact that each indicator was studied independently of others, despite the their interdependence. It concisely describes the beginnings of total quality in industry in Japan and its movement to the United States and its slow recognition and acceptance by the U.S. health care industry.

The United States Health Care System and Quality of Care - The chapter begins by stating that there is no U.S. health care system; however, it then proceeds to state that the chapter will review the evolution of a system, rather than, as presented, the evolution of U.S. health care. This chapter is primarily a review of the funding of health care, including different models of compensation associated to some degree with different models of physician-hospital services.

Principles of Total Quality in Health Care Organizations - Basically a collection of articles that reflect different gurus' views of quality, this chapter commences differentiation of quality improvement from quality assurance. It emphasizes that the professional ethos of physicians is to continuously improve existing practices. In my opinion, it should provide an impetus to the reader/learner to go beyond the "classics" and to question, for example, the truism of O'Leary's delineated misconceptions, including the dictum that to focus on outcomes (to the exclusion of process) will lead to inspection or quality assurance, not quality improvement.

The Implementation of Total Quality - The authors describe their own concept of implementation, underlining the need for people/organizations to develop a glossary of terms (which would have been a useful addendum to this chapter) to understand principles of CQI and the tools, processes, and methodologies for quality improvement. The authors indicate that team building is important but the chapter moves from team building in general without discussion to a specific reprint of a patient care-directed team article, which itself references articles regarding seven processes for team meetings but does not outline for the uninitiated what those processes should be. This chapter is at best a reference chapter; it is not a basic description for an unknowledgeable student.

Data Management for Total Quality - This is a very good overview of statistics and other quality improvement tools. However, it would be helpful to include a standard Z score table so that a student has access to appropriate data to work through a sample size formula. one objective of this chapter was to discuss the transformation of data to information, and I am not certain that this was fully developed. This transformation is vital, and some discussion of how these tools facilitate that transformation would have been appropriate.

Cost and Health Care Quality - An excellent reprint of an article comprising virtually the entire chapter outlines ways to account for the costs (prevention, appraisal, failure - internal or external) of quality.

The Law, Ethics, and Total Quality - The law, as described in theory and in case examples in this chapter, seems more directed to quality assurance, i.e., finding bad apples, than to quality improvement or total quality, despite the authors' attempt to link law with the latter philosophies. The ethical component of quality is stressed as being complementary to the legal aspects.

Total Quality and Management Philosophies - This is an excellent summary of organizational cultures and philosophies, especially in the initial portion of the chapter. It then moves on to cheerleading and to suggestions regarding how to lead the change and transform the organization. It is an exciting, dynamic chapter.

Integration of Total Quality and Quality Assurance - This article provides an excellent discussion of quality assurance versus quality improvement; although the authors believe that QA and QI need to be integrated, the emphasis is on total quality and less on how to integrate QA into total quality. They note the value of using common elements of both processes to create a total quality culture, but they continue to distinguish between the two rather than link them. Nonetheless, it is a good basic article for distinguishing between these two dimensions of quality.

Outcome Management and TQ - This chapter clearly places outcome management in perspective; further, it recognizes that outcome management embodies all of Donabedian's triad of quality - structure, process, and outcome - as interdependent variables.

Research and Total Quality - This is a good summary of research in total quality, with a "rah-rah" flavor to it.

Total Quality within the VA Health Care System: A Case Study - This is a fine review of the trials and tribulations involved in developing and implementing TQ, especially in an organization where a collaborative, open-communications culture was relatively nonexistent.

Overall, I believe this book is an excellent value and is very insightful and provocative in its portrayal of total quality. It would be a very positive addition to a physician executive's library.

BOOK REVIEW

In this column, members of the College's Vantage Council review books that they have identified as being of interest and value to the medical management profession. Reviews from other sources are included in Physician Executive as space permits.