Superior Productivity in Health Care Organizations: How to Get It, How to Keep It, by Paul Fogel, Baltimore, Md: Health Professions Press Inc, 2004. 208 pages, softcover, $26.95.

Although Paul Fogel's primary objective in producing this book is to provide the managers of health care organizations with tools for raising productivity, he also makes a good case for improving the quality of care along the way. Too often the contribution of high quality, whether of services or products, to productivity is overlooked by writers on both subjects. Poor quality hospital care that results in clinical complications, intensified pressure on resources, and extended hospital stays certainly interferes with the productivity of the organization and of the whole health care delivery system.

In his first chapter, "The State of the Union," Fogel addresses the currently popular strategies for reducing costs, including replacing highly skilled professionals with lower-waged, less-skilled personnel. He makes the point that although this dilution of the skill mix can reduce payroll, it will also increase the number of personnel, the need for supervision and training, and the occurrence of more interruptions and handoffs, with possible unfavorable consequences for the quality of patient care.

The author's analysis of accountability and of the relationships among responsibility, authority, and mission is excellent. It applies not only to the economic aspects of productivity but also to the quality management effort that contributes to high productivity. He argues that "productivity management is not about hardware or software technology[horizontal ellipsis]No amount of budget policing can compensate for individual responsibility and accountability." 1^(p102)

In his fourth chapter, dealing with monitoring and reporting, Fogel asks, "Whom should the organization put in charge-the managers or the software?" 1^(p106) Good question. He warns against becoming seduced by technology at the expense of professional judgment and common sense, worthwhile advice whether you're talking about quality management per se or productivity programs. In his discussion of the impact of complex computer systems in evaluating service operations, Fogel points to the law of unintended consequences. His thesis is that the resultant centralization of decision making dilutes responsibility and accountability at the departmental level.

The author's insights into the politics of productivity apply equally to the political aspects of organizational quality management. Sometimes leadership's task is to reconcile competing agendas. In his summary on the politics of productivity, Fogel seems to suggest that he doesn't view quality and productivity as conceptually joined. He states that departmental service enhancements "can be preserved while still improving overall organization productivity." 1^(p106) This reader would argue that quality and productivity are two sides of the same coin.

This book is a quick read and extremely interesting. Paul Fogel, MBA, is president of Executive Information Systems, Inc, a consulting firm to health care organizations. He is a very good writer, and has organized his topic beautifully. The sidebars are well chosen, and contribute to the easy conversational tone of the text. The glossary of terms used in the study of productivity is an especially welcome feature. This book can be highly recommended to anyone interested in enhancing the productivity of a health care organization, whether a group practice, a community hospital, or a university medical center.

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