On Track to Quality, by James K. Todd, Pittsburgh, PA: Lighthouse Point Press, 2006. 138 pages, hardcover, $ 19.95.
Attempts to define quality inevitably confront widespread differences in perceptions of quality. The author wrote this book in order "to compile the perceptions of a diverse group of observers from many walks of life, in order to discover the elusive definitions of quality" (p. 6). He uses a venerable literary device-the trapping of a group of travelers by a snowslide-to create a setting for his exploration of the various perceptions of quality. He and his fellow travelers begin by addressing the question, if we cannot define quality, how can we recognize it? Todd himself wonders whether quality is relative.
As the discussion, featuring a Chaucerian structure of anecdotes, goes on, the author derives certain conclusions from it, and from them formulates a list of 13 "Quality Principles." In the discussion of the relationship between an organization's mission and values, and of their influence on the definition of quality, Dr Todd addresses a subject that too often is ignored in discussions of quality in health care. The concepts of structure and process as they apply to quality are examined. The stories illustrating these concepts are very apt. In another chapter, the author's algebraic definition of outcome summarizes an interesting approach. The discussion gets down to earth with an exploration of the uses of standards and measurement. Customer satisfaction and the complexities of defining and measuring it are explored at length.
In his chapter on the relationships between price and quality, the author gets in a few licks at the expense of managed health care organizations and plans. After a rather superficial, meandering examination of the subject, he finally arrives at the conclusion (Quality Principle #9) that value is determined by quality at a price. In developing his tenth principle, Todd employs a graphic model of "the synergistic synthesis of quality," embodying mission, structure, process, outcome, and customer satisfaction, and applies it to his ideal quality health care company.
Many students of evaluation of health care performance may be taken aback, as I was, by Todd's assertion that "Quality is dependable, yet adaptable" (p. 112). Is he referring to the changing face of good health care over the centuries, or to the application of different standards of care to hospitals that serve different demographic groups? Neither, as it turns out. Apparently, he is trying to make the point that how you define quality may depend on the circumstances and the expectations of the parties. He illustrates this point of view with an explanation by a lawyer-traveler of the concepts of a "quality contract" between the parties to a transaction and of constructive legal strategies. In a clumsy and fairly irrelevant dialogue involving a long-married couple, the author tries to point out the positive effect of adaptability on the stability of a relationship, presumably contributing to a high level of quality in the relationship-something of a stretch.
In the following chapter, Todd explores the structural and technical infrastructure that make process improvement possible, and concludes that definitions of quality are time dependent. By that he means that the definition of quality depends on the particular point in time at which it is being measured. Todd's group of travelers then addresses the question of how the perception of quality adapts to changing circumstances. They agree that those who seek high-quality performance cannot afford to become complacent, because truly achieving and maintaining high levels of quality entails constantly challenging, evaluating, and improving performance. The weak point in the discussion is the expressed notion that the development of new products can be equated with improving quality.
This little (138 pages) book is an entertaining, easy read. Well-chosen examples of the components of quality, and of how to measure them, are drawn from the worlds of business and sports. Dr Todd, who writes well, has tried to present a meaningful exposition of a very complex subject in a nontechnical style. This is no easy job. The question is, for whom did he write this book? Readers who are students of quality assessment and improvement would find the discussions superficial, dated, and sometimes off the mark. Readers who might benefit from the simplified anecdotal approach are unlikely to be all that interested in the philosophical and social underpinnings of quality management systems. The author mistakenly ascribes the development of Motorola's iconic quality improvement system, Six Sigma, to General Electric. There is a short list of references, but no subject index.
Jean Gayton Carroll, Editor
Quality Managment in Health Care, Associate Professor, Health Systems Management, Rush College of Health Science, Chicago, Ill