In a challenge to the common reliance on control charts based on performance data, Hart, Lee, Hart, and Robertson argue in favor of a new class of control charts based on a combination of risk-adjusted and observed data. To these attribute control charts they ascribe such benefits as reducing variation arising from uncontrollable changes in patient mix over time. In addition, they suggest that using the proposed charts should reduce the rate of "false alarm" deviation, thereby fostering more efficient use of resources. The authors acknowledge the caveat that not all performance measures lend themselves to risk-adjustment procedures. In addition, they point out that "if the patient mix is very stable over time, the marginal effect of risk-adjusted control charts may be negligible even for outcomes measures."1 Their research design uses multivariate logistic regression models for the analysis of three performance measures from a sample of 43 health care organizations.

LaBresh and Tyler, in their report of a collaborative model for hospital-based secondary prevention of cardiovascular disease after treatment for acute coronary syndromes, focus on closing the gap between knowledge and practice. The model on which they report, incorporating the American Heart Association's Get With The Guidelines program, was developed and tested in 24 Massachusetts hospitals, beta tested and refined in Southern California hospitals, and is now undergoing a phased national pilot study. Program implementation emphasizes the role of stake holders and the application of evidence based therapies in forestalling the recurrence of cardiovascular disease. LaBresh and Tyler provide a detailed explanation of each step in the collaborative process that led to demonstrated breakthrough change. They estimate that "[horizontal ellipsis] if 85 percent of patients hospitalized with a cardiovascular illness were treated with aspirin, beta blockers, angiotensin-converting enzyme inhibitors lipid altering therapy, 80,000 lives could be saved each year."

Houston, Gentry, Pruitt, Dao, Zabaneh, and Sabo describe the application of a revised quality management process to the prevention of nosocomial pneumonia in cardiovascular surgery patients at St. Luke's Episcopal Hospital of Houston, Texas. In this project, winner of a Premier system award, the multidisciplinary project team substituted the hospital's new quality management process for its traditional process based on the "plan, do, check, act" cycle. The steps in their revised approach are "select [a problem to be resolved], examine [the factors creating the problem, through retrospective chart review], act [develop and implement the action plan], evaluate [results of the program activity], and decide [maintaining long-term staff commitment and involvement]." Over the 5 years of the revised system's implementation, the incidence of nosocomial pneumonia after cardiovascular surgery declined by 50 percent.

The crucial role played by data and information in managing the overall quality of clinical care and the provider's financial health is the starting point of the project reported by Marco and Buchman of The Medical College of Ohio, Toledo. As they point out, ultimately the quality of certain crucial components of the clinical documentation of each episode of care depends on the behavior of the physician. Improving physicians' documentation should improve not only hospital efficiency but also the quality of clinical care. Using the operating room as a model for other hospital departments, the project team launched a documentation improvement project aimed at bringing about measurable change in the documentation behavior of the hospital's surgeons. The intervention consisted of asking each surgeon to sign and return a statement to the effect that documentation was important and that he or she supported the Medical College Hospital's efforts (in the direction of good documentation). After analysis of surgeons' responses and of documentation after this intervention, the authors report that the proportion of completed documentation improved significantly for those physicians who had signed and returned the memorandum of agreement. They conclude that even what they describe as a small, private commitment to an objective, when expressed in writing, can bring about measurable behavioral change.

St. John Health System, operator of eight merged acute care institutions, formulated five patient safety goals in response to the 1999 Institute of Medicine report addressing patient safety. Wilson, Gentile, Joseph, and Tersigni report on the systemwide implementation of these goals. The system's plan addresses such matters as the appointment, credentialing, evaluation and deployment of physicians; the provision of adequate training to all patient care personnel; accountability issues associated with peer review and board oversight; emphasis on pharmacy safety through ongoing review; and applying the principles of evidence based medicine in drafting clinical protocols and standing orders. The authors' account provides detailed explanations of the background, structure, and processes of the patient safety enhancement program.

In their study, Johnstone, Hendrickson, Dernbach, Secord, Parker, Favata, and Puckett set up a test of the usefulness of the Six Sigma approach in optimizing ancillary services performance. The services studied were radiation oncology, laboratory, blood bank, and pharmacy. Among their findings were that certain ancillary services do lend themselves to Six Sigma processes, and that defects per million opportunities (Six Sigma's "DPMO") varied with the biological complexity of the services and the degree of automation available to practitioners.

Jane and Dominguez examine consumer satisfaction as a component of quality in health care. In doing so, they look at consumer expectations and preferences as these are used in developing marketing strategy. Professor Noritake Kano of Tokyo's Rika University developed a model for analyzing consumer preferences in marketing studies. Using the investigative structure provided by Kano's model, the authors have studied the expectations and preferences of consumers of health care services. They assess the advantages and disadvantages of qualitative research methods (using focus groups and interviews) and quantitative research methods (using closed end questions and questionnaires) in this field.

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