Before reading this book, I was under the impression that total quality management, continuous quality improvement, and other new names for what we used to call quality assurance were methods dreamed up by hospital administrators and regulatory agencies to confuse and control physicians. The authors of this book on improving clinical practice report that my opinion is shared by most physicians. After having read the book, I still believe that total quality management, continuous quality improvement, and so on are usually used by administrators to control and manipulate physician behavior. On the other hand, the authors have convinced me that this need not be the case.
Many practicing and academic physicians are currently involved with committees or organizations that monitor the quality of medical care. The most positive aspect of this book is that, after reading sections of it, one may be able to ferret out some valuable techniques for improving patient care from among the smoke, mirrors, and jargon that appear to permeate what we have traditionally referred to as quality assurance activities.
This small book suffers from the ills of multiauthor works. Some chapters are useful, and others appear to be irrelevant fluff or fillers. There are important messages that one can take home. The authors have convinced me that continuous quality improvement has the potential to enhance the scientific bases of the daily practice of medicine. The methods described go back to W. Edward Demming and his now 50-year-old approach to improving industrial production. Perhaps facetiously, the authors talk about type 3 and type 4 error. Type 3 error is "solving the wrong problem," and type 4 error is "mistaking the problem for the solution." These are nightmares with which we all live; the authors try to help us avoid them. The first few chapters are poignant. It is pointed out that we need to measure total care and outcomes and to be wary of one element of the medical care system "suboptimizing" itself but not supporting the end result. The methods seem painfully simple after one reads the first 100 pages: Identify a cohort of similar patients, set priorities for outcomes, identify the steps in the process of care, and use measurement and analytic techniques to define variations in outcome.
This book does not report anything new and different. It does offer a concise, easily understood way for persons with only a basic knowledge of medical care and quality improvement techniques to achieve some fluency in the methods that are going to become part of our everyday existence. If we understand them, maybe we can make them work for us and truly improve medical care. If one is going to sit on a hospital or medical group committee charged with improving the quality of medical care, the few hours one spends absorbing the salient points of this book are well worth the effort. With all of the new clinical information that the practicing physician needs to ingest, spending time to understand quality management may be too much to ask, but the time spent in this area is bound to increase, and more and more physicians will become involved.
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