While improvement science is what Quality Management in Health Care is all about, we don't often see references in the current literature to 3 towering improvement scientists and their work in establishing the foundations for scientific analysis of improvement methodology: Deming and Shewhart, in industry, and Donabedian, in health care. Perla, Provost, and Parry, starting with Deming's seminal System of Profound Knowledge, develop and present 7 basic propositions that underlie the science of improvement. In contrast with most methods-focused improvement literature, they suggest that striving to provide optimal health care is a moral imperative for the practitioner.

The title, "Pay for Performance" ("P4P"), certainly raises an expectation that health care should follow the same outcome-reward incentive pattern as any business enterprise. Young examines this concept in the light of P4P's actual performance record and suggests that it hasn't been working as it is supposed to, largely because payers and providers have not cooperated in designing P4P plans. He cites more recent developments as pointing to the gradual rise of a social capital model of cooperation. The effectiveness of paying for performance is examined from another point of view discussed by Bhalla, Schechter, Strelnick, and their coauthors, Deb, Meissner, and Currie. These authors report on the associations between care patterns and P4P in a Hispanic-Latino-Spanish-speaking patient sample.

We're all always eagerly searching for the quick fix, the magical ritual, the fail-safe remedy that we can implement between breakfast and dinner. Six Sigma, borrowed from the manufacturing world, is one such phenomenon. To an increasing extent, judging by the literature, health care provider organizations around the world are trying it out in the interest of increasing their own productivity and efficiency. Delli Fraine and her coauthors, Wang, McCaughey, Langabeer, and Erwin, ask "To what end?" They raise questions both about the various applications of Six Sigma and about the quality and rigor of many of the research designs cited in the literature. They ask whether Six Sigma is actually being used to its full potential.

Another take on Lean Six Sigma is provided by Aleem. He offers 10 lessons that were learned in the course of one green belt training program and in applications of the Lean Six Sigma approach to health care project management. His concretely stated summaries embody practical advice that would be of interest to health care managers.

Delving into the health care quality evaluation and improvement systems of other nations, and comparing and contrasting them with the United States system, may not seem a very engrossing pursuit to most people, but it interests this editor. For one thing, overseas systems have been, from their beginnings, directed through regional and national governmental agencies. This presents a distinct contrast to the profession-driven voluntary program born in Chicago around 1915. Maarse, Ruwaard, and Spreeuwenberg allude to the establishment of the Dutch system of clinical guidelines for health care procedures that took place in 1979 with formation of a working group charged with the development of a guideline for blood transfusion that could be used as a protocol for peer review. More recent developments include the formulation of standards of care designed to address not only clinical aspects but also patient experiences. The authors trace these developments and discuss 5 strategic challenges facing the working groups as well as the professional societies and academic institutions that are focusing attention on formalizing health care standards.

Paccagnella and his coauthors, Marcon, Rebuffi, Garna, Mauri, Maccari, Paiusco, and Spinella, set out to remedy what they see as the paucity of studies in which the organizational aspects of health care are explored in a structured way. In-home enteral feeding programs are provided by 5 local governmental health care administrative agencies in Italy's Veneto region. Comparison and analysis of the 5 agencies' organizational structures and clinical procedures showed that they were not all adhering to the same standards and clinical guidelines. The authors point to the benefits that can be expected to accrue as a result of enterprises such as this project in fostering experience sharing and cooperation among the clinicians in the 5 agencies.

-Jean Gayton Carroll, PhD

Editor