This issue of QMHC includes several contributions to the methodological aspects of improving the quality of patient care.
Exploring the appreciative inquiry approach to quality improvement, Carter and coauthors present a case study in which they go through the 4 steps-Discovery, Dream, Design, and Destiny-that make up the appreciative inquiry process. In their discussion of statistical process control, Matthes and coauthors review the basic theory underlying statistical process control methodology and present effective tactics for educating health care professionals in its use. They argue for an aggressive approach in utilizing data in the course of improving the quality of care.
In a case study, Boehringer and coauthors present another instance of the potential effectiveness of a very simple, low-tech device in improving hospital care by reducing the likelihood of errors and misinterpretation in responding to physicians' orders. Against the background of general agreement that complications increase length of stay, early readmission, and the cost of care, Sparling and coauthors, in a matched sample controlled study, document the actual cost penalties of a complication in a pediatric population.
Printezis and Gopalakrishnan, studying the use of Toyota Production Systems as a quality enhancement and error reduction strategy in health care, point to 3 key factors in the effectiveness of Toyota Production Systems in health care: addressing and reducing waste, the personal involvement of staff in making improvements, and the use of a very succinct reporting model called the "A3 Reporting System." Following a review of the clinical benefits associated with definitive control of hyperglycemia in hospital patients, Reynolds and coauthors propose the adoption of a hospitalwide standardized approach to the management of hyperglycemia in place of the customary management with retroactive "sliding scale" insulin administration. The authors emphasize the importance of hospital administrative support and of education in implementing a standardized management program.
Rohrer and coauthors, studying Mayo Clinic patients, present the case for referring all patients whose body mass index (BMI) is more than 35 to weight management programs, monitoring patients whose BMI is between 30 and 35, and encouraging patients with BMI more than 25 to avoid weight gain. Homa discusses the use of a technique called "analysis of means" (ANOM) in uncovering such phenomena as the patterns clinicians follow in referring patients for care and its potential in pointing the way to further improvements in patient care. The author presents examples of the use of the ANOM technique to investigate referral rates and patterns among providers.
Moving upstream from the hospital setting to the primary care office, Zink and Fisher examine the issues involved in the clinician's office assessment of possible child abuse and elder abuse. The authors have developed and tested a modified version of the hospital assessment instrument for use by office professional staff in determining the presence or absence of family violence and the need for referral. They report that, to their knowledge, this is the first example of such an instrument designed for use at the primary care office level.
Caspari and coauthors report on the second phase of a 3-part study of the impact of the aesthetic quality of their surroundings on hospital patients. In this second phase, they analyze patients' perceptions of and reactions to their physical surroundings as these were reflected in questionnaire responses.
Jean Gayton Carroll, PhD
Editor