le="FONT-SIZE: 12pt; mso-bidi-font-size: 10.0pt"> – attributes of care providers, settings, and arrangements.


Outcome variables describe some relevant characteristic, usually of the patient, after provision of care that is presumed to result from the care given (ie survival, death, length of hospital care, complications, etc.). These may be difficult and expensive to measure.


Process variables describe what care is provided or characteristics of its provision. (ie doctor’s orders, the procedure to obtain a test and its results, or the steps by which a patient gains access to a doctor). This may still be difficult and expensive to do. But, it is not as difficult to do as outcome measurement.


Outcomes variables are the least expensive and easiest to obtain.  These variables describe the characteristics of inputs to care processes (ie hospital’s physical structure and condition, doctors’ training and qualifications, nursing training and competence, etc.). 27




“Toolbox” and Methods


Tools   Ever since Shewhart, quality engineers have used innumerable tools to achieve process and outcome measurement. Although these tools have been applied in industry for decades, they have only recently found application in health care. Part of the reason for their increasing adoption by health care managers is the reliance on statistical thinking rather than rigorous statistical analysis. 28 Statistical thinking is the approach of quality engineers that utilizes descriptive statistics to validate quality evaluations, without elaborate mathematical analysis. Descriptive statistics includes mean, variance, and standard deviation to evaluate quality improvement opportunities. Quality engineers have seven frequently used tools available for each of the four steps in the quality improvement cycle. 29  Additionally, payors for health care and governmental agencies are expecting reporting of results of care processes via two other forms of reporting – report cards and instrument panels – from providers and HMOs.






1.       Pareto Charts

2.       Fishbone Diagrams

3.       Histograms

4.        Run Charts


5.       Check Sheets


6.       Flowcharts




7.   Control Charts

                                                REPORTING RESULTS

8.   Report Cards

                                                            9.   Instrument Panels



These tools have come to define the classic approach to quality improvement, and they are used to insure that each step in a quality improvement process provides valid conclusions.


PROBLEM IDENTIFICATION tools define the source of variation in a process, allowing planning to decrease inappropriate variation and improve quality. In order to validate the problems identified. Examples of these ‘cause and effect’ tools are the Pareto chart and analysis and the Fishbone diagrams. The Pareto chart (see Chart#1) 30 and analysis is used when dealing with chronic problems and helps one identify which of the many chronic problems to attack first. The chronic problem with the highest number of events will show up on the Pareto chart with the tallest bar, which represents the most frequent occurring problem. The idea behind Pareto analysis is the 20/80 rule in that 20% of your errors / customers / input accounts for 80% of your complications / income/ output.


Chart#1-Pareto Chart



















Fishbone diagrams are another form of cause and effect methods whereby the step-by-step process is followed from beginning to end in a way to look at each stage of production. In this way factors involved in each step are determined, identified, isolated. DATA must be COLLECTED and analyzed, and a checksheet (data collection sheet) design provides a scientific approach to gathering information to improve the validity of decisions and interventions.


INTERVENTIONAL DESIGN makes use of the fact that variation in a process exists because the process does not operate the same way every time. To get a handle on how the system ideally operates or should operate, standardization of the process must occur.

Flowcharting has proven extremely valuable for health care managers in understanding and optimizing processes. Often, the very act of producing a flowchart (see Chart#2) uncovers problems in process flow that respond to simple intervention. In more complex processes, flowcharting may present the only means of understanding the true structure of a system.





































PROCESS CONTROL is considered by many as the most critical measure of quality improvement. Through the use of statistical process control charts, data can be expressed in terms of means and up to three standard deviations above and below that mean, over which data collection points are plotted. Based on these data points, variations in the process that are outside expected limits can be identified and targeted for intervention.


Control Charts (see Chart#3) are most useful for ongoing processes in which variation is a source of cost and diminished productivity, and these statistical models allow rapid analysis and intervention for active processes. In health care, control charts are useful for analyzing performance and outcome measure in diagnostic and therapeutic systems of care for specific disorders or preventive care. Using control charts, health care managers can usually identify sources of variation that determine approaches for improvement.


Chart#3-Control Chart
























In the Control chart above, we noted significant variation in turn-around-times for operating room specimen delivery. The variation was outside of the dotted line which represented upper control limit averages that would normally be understood by chance variation. By instituting a change in the system at week 16, we were able not only to reduce the special cause variation that caused the extreme variation, but we were also able to reduce the chance or common cause variation to essentially zero by week 20(or week 4). 31 


Reporting Results One of the advantages of the quality improvement approach in health care is the application of an evidence-based approach to decision making. One of the major criticisms of the PDSA cycle approach and the evidence-based approach to health care improvement is the lack of a scientific basis around the recommendations for care made by this approach. Since a substantial majority of medical care is based on an individual clinician’s anecdotal experience, rather than scientific evidence, many decisions on medical necessity lack the kind of scientific validity that physicians desire.

Thus, disputes arise as to the meaning of disparate clinical experience. While the traditional clinical trial approach insures that critical analysis, however costly and time-consuming, will continue indefinitely as medical science advances and improves, the utility of PDSA data in the quality improvement process should be intuitively evident, as effective, efficient and explicit. While criticized in some circles as ‘statistical-lite’, CQI and PDSA have in fact as one of their central dogma the statement, “In God we trust, all others bring data.” Instrument panels and report cards are functional ways to display this data. 


Instrument Panels  Pareto-charts and control charts display frequencies of events and outcomes well, as described above. Frequently the quality manager, or process improvement team, chooses key variables occurring during a quality improvement project and groups these data displays in an array of multiple figures or tables that capture the events and work. These instrument panels: 1) illustrate real-time monitoring as action is taking place, 2) they present information, at present time, that is dynamic and occurring in “real time” that may target future goals, and 3) they empower those improving the process thru informed decision making. 32 An example of a simple instrument panel in real life is the dashboard instrument display in your car that helps you operate the vehicle during travel. It shows you speed, mileage, fuel reserve, gearshift selection, etc.-- all of which are useful to you while traveling to a destination. An analogous healthcare instrument panel would be a display of data, perhaps histograms and control charts, that would advise and monitor a quality improvement teams efforts to treat acute myocardial infarction inpatients with timely thrombolysis, administration of aspirin and beta-blockers, length of cardiac care unit stay, complications of care, and enrollment in smoking cessation and rehabilitation efforts. In summary, instrument panels convey a careful and thoughtful approach to the display of data that is very helpful in stimulating action toward a goal.



Report Cards  During quality improvement work, a health care manager may be asked to present information, such as outcomes data in the form of charts or instrument panels, to upper management, corporate boards or leadership, community officials, payor organizations, or regulatory agencies at the state or federal levels.  These information displays usually report results that demonstrate accountability for care. They usually display past successes or lack thereof. This display of data is: 1) somewhat static,

2) usually reflecting past summaries of information, 3) shows results that may be open to judgment that may produce apprehension, rejection, or sometimes joy, and 4) center around conclusions about outcomes on or around average expectations.

Specific report card examples are: 1) state health department reports on local cardio thoracic surgery results reported as for mortality and cost for coronary artery bypass surgery 33  or 2)  Health Plan Employer Data Information Set (HEDIS®) reports to payors or employers on health plan quality issues relating to immunizations, cancer screening, acute and chronic disease management, customer service, access to care, and claims processing. 34


Methods  Good intentions, teamwork, data acquisition and analysis, and changes tested in improvement cycles are all essential to improving healthcare. All too often, the focus for improvement results in personal “shame or blame”. When, in fact, studies show that most often failures are due to process or system deficiencies that lead to inefficiencies, error, or poor results. Flow charts can help the manager visualize the process that exists. However, usually in healthcare processes and systems much more complex and even at times chaotic. 35  These complex process interactions in systems are best evaluated using methods known as “root cause analysis” (RCA) or the “theory of constraints” (TOC).


            Root Cause Analysis  Root cause analysis is a method which can help individuals learn as much as possible from adverse events or poor outcomes of processes in systems. It is not enough to just learn about what happened when expectations fail to be met. It is more important to know WHY something happened and learn how to prevent a recurrence.  A root cause is the most basic reason that a situation did not turn out ideally. Most often, a root cause is a known or unknown system vulnerability (human weakness is almost never a root cause). In complex scenarios, there may actually be more than one root cause –seemingly a paradox, but not. 36 The evaluation of root causes involves a rigorous thoughtful team approach to flow diagramming and construction of cause and effect diagrams after consideration of: 1) failures in human factors of communication, training, and fatigue or scheduling, 2) environmental or equipment failures, 3) factors relating to rules, policies, or procedures, and 4) barriers. One enters into each of these areas of consideration asking the question “why” at least five times, thus delving deeply into each process or system interaction beyond simple explanations. 37


            Theory of Constraints   Similarly, theory of constraints is a method of evaluating multiple interactions among processes and systems that ultimately effect thru-put. It involves a thinking process that emphasizes: 1) WHAT to change, 2) TO WHAT  to change, and 3) HOW to cause a change. By rigorously identifying conflicts in a problem system, one arrives at a ‘core conflict’ and then goes on to construct a complete solution having considered complex interdependencies that exist in a problematic system. Changes are considered and proposed, but only tested after thoughtful evaluation of interactions among processes and systems that may be interrelated. 38 In effect, TOC involves RCA in principle. However, TOC goes beyond conventional cause and effect diagrams by constructing diagrams that show interdependencies and interactions. This thinking process and resultant diagramming helps focus improvement team members on identifying the solutions which may lead to a breakthrough solution-- especially in thru-put scenarios. 39


Evolving Practices and Initiatives  The historical contexts of the manufacturing and service sectors of the economy have influenced the tools and methods being applied to health care system quality management. Presently within the business community, a multitude of process improvement champions seem to be vying for attention and leading others toward a “best” method. Each champion advocates adoption of his or her favored improvement methodology. Three current methodologies include “Six Sigma”, “Lean Thinking”, and TOC. As is usually the case, there is not one method for all situations. An understanding of these programs, their application, and implementation is worthy of brief discussion. 40 In addition, the business improvement programs of the Baldrige Awards, ISO 9000, and principles involved in the management of high reliability organizations

(nuclear power plants, aviation, and aerospace) are entering the environment of healthcare as coalitions of businesses, payors, providers, and regulators come together. A brief summary of these follows.


            Six Sigma   Six sigma refers to the statistical likelihood that there will only be 3.4 failures or defects in a million opportunities. This quality management method was first implemented in industry at Motorola. In addition, it has been popularized by tremendous successes in management at General Electric.  Some experts believe it should be equally as successful in healthcare. 41 Reduction of variation in the areas of medication administration, surgical procedures, assignment of caregivers, emergency treatment triage, patient falls, and disease management are just a few applications where the DMAIC – Define, Measure, Analyze, Improve, and Control-guidelines of six sigma resemble and complement PDSA cycles of improvement. The focus of six sigma is centered on reducing, and hopefully removing, failure and defects within work processes.


            Lean Thinking   Lean thinking is sometimes called lean manufacturing and was popularized in manufacturing by the Toyota production system. “Lean” focuses on the removal of waste in work environments. Waste is defined as anything not necessary to produce the product or service. The common measure is ‘touch time’-- the amount of time the product is actually being worked on or touched by the worker. Frequently, lean’s focus is manifested in an emphasis on flow through a process. Five essential steps in lean are: 1) to identify features that create value, 2) identify the sequence of activities called the value stream, 3) make the activities flow, 4) let the customer pull the product or service through the system, and 5) perfect the process. Recent collaboration between General Motors and its employee’s healthcare providers have reduced costs and improved outcomes 42 – truly a win-win for the purchaser, users, and providers of health care.


            Baldrige Awards   The Malcolm Baldrige National Quality Award was created by Public Law 100-107 and signed into law on August 20, 1987. The award is named for Malcolm Baldrige, who served as secretary of commerce from 1981 until his untimely death in a rodeo accident in 1987. Baldrige’s managerial excellence contributed to long-term improvement in the efficiency and effectiveness of government. The award not only recognizes quality: but, also establishes a framework within which quality initiatives take place. Most organizations that apply for the award, believe that even greater gains accrue through evaluating their system than may result from being awarded one of the coveted awards. Thru the Baldrige performance excellence criteria any organization can improve overall performance in seven categories- leadership, strategic planning, customer and market focus, information analysis, human resource focus, process management, and business results. 43 More information is available at: http://www.quality.nist.gov/ .


            ISO9000   ISO 9000 is a series of international standards first published in 1987 by the International Organization for Standardization (ISO), Geneva, Switzerland. It is updated nearly yearly. Expectations centered about “standards” were the inspiration for Shewhart et al at Western Electric in the 1920s. Since then, and more recently, standards have ensured that materials, products, processes and services fit their purpose. ISO defines standards as documented agreements containing technical specifications or other precise criteria to be used consistently. These criteria take the form of rules, guidelines, or definitions of characteristics. A current ISO edition applicable to healthcare is ISO9000: 2000. Under the ISO 9000 approach, organizations establish written quality management systems based on the quality elements listed in the ISO 9000 requirements documents and its updates. These standards include domains defining: 1) the quality management system, 2) management responsibility, 3) resource management, 4) product realization, and 5)measurements accompanied by analysis and improvement. 44 Once these quality management systems are documented and implemented, a third-party registrar audits the endeavor for conformance. If conformance is verified, the organization is recognized and registered as a certified entity. 45  ISO increases the reliability and effectiveness of goods and services. ISO certification is useful in healthcare because it conforms to the healthcare sector, as JCAHO has traditionally intended; yet, it appeals to the manufacturing or service sectors because of their familiarity with ISO methods and assurances.

Additional information is available at: www.iso.ch/iso/en/ISOOnline.frontpage .


            High Reliability Organizations- “Management of the Unexpected”   Lessons have been learned from other complex and error-prone environments that can, and must, be applied to management of health care systems. The aerospace, aviation, and nuclear energy industries – known of as high-reliability organizations (HROs)-- must consistently

produce safe, reproducible, error-free services and products.  The National Patient Safety Center has been charged with teaching applications of these principles and actions to reduce human and system error in healthcare organizations. Recently Weick and

Sutcliffe 46 have described the five hallmarks of HROs. These five are: 1) a preoccupation with failure, 2) reluctance to simplify interpretations, 3) sensitivity to operations, 4) commitment to resilience, and 5) deference to expertise. Tools for assessing an organization’s preparation and implementation of “mindful management” are essential for the management of quality and error prevention in medical care systems.








Future Directions


Despite the long history of quality theory and practice--both inside businesses and in the healthcare sector, the availability of usable tools and methods, the influence of nongovernmental and governmental and policies, and JCAHO Accreditation requirements; it seems difficult to implement and sustain quality improvement efforts in daily operations within healthcare settings and systems. 47  Therefore, one must pose the question, “What will lead to successful implementation and sustained quality improvement in health care systems in the future?”


First, economic forces will continue to drive efforts to improve quality. Employers who pay their employee benefits--especially large businesses such as General Electric, General Motors, AT&T, IBM, Boeing and others trying to compete in a world market in which other countries spend less on benefits for employees; and thus, more on research and development-- are forming consortia such as the Leapfrog Group. 48 These business leaders are thinking about steering their employees health care dollars toward those providers with the “best quality” and “value” as evidenced by: 1) computer order entry to avoid medication errors, 2) specialist staffing of high-cost Intensive Care Units, 3) volume requirements for high risk procedures for optimal outcomes, 4) and electronic medical records for information access. Leapfrog is creatively partnering with JCAHO and Premier Inc.--a provider alliance. They are also sharing provider information with employees. 49


Secondly, scandals regarding poor quality of care 50 and attention focused on life threatening errors in daily medical care, 5,51,52 in the United Kingdom and here in the United States respectively, have become household news. These have resulted in reduced public trust in their care providers. The British National Health Service and the Institute of Medicine are advising healthcare providers to seek “breakthrough improvements” in the way they function daily. The Quality Chasm, 6 recently published by the Institute of Medicine, suggests ways to bridge the gap between what patients expect and how providers currently perform. Continued pressure from coalitions of healthcare users and those paying for healthcare will only accept “best practices’ based on “scientific evidence”. The challenge for providers will be to translate best practices from the research institutions (efficacy of care) into practical processes in multiple care settings (effectiveness) without over utilizing expensive technology (efficiency) while not under utilizing resources (ethical conflicts due to misaligned incentives).


Additionally, visionary healthcare management leaders-- such as those who have reported on the work of the National Demonstration Project on Quality Improvement in Healthcare—are looking forward. 53 Health services researchers and educators continue to seek future models for quality management in healthcare. 54


On the other hand, skeptics believe --perhaps realistically so-- that only new economic incentives or models will succeed 55 in driving successful implementation of sustainable quality improvement action in health care. These skeptics propose that when a “business case” for quality is demonstrated, only then, will enthusiastic followers rally. Given what some consider being only small limited projects and the complexity of healthcare stakeholder expectations, a quantitative business case seems elusive. However, some reputable investigators believe that the business case for quality in health care is certainly qualitatively measurable. 56 All the same, there seems to be no mistake about consumer demand and expectations for clinical quality coming from several perspectives – individuals and communities. 57


Summary  The study of quality improvement is crucial for health managers to effectively promote cost effective, high quality, high valued health care. Patients, payers, and regulators are and will continue to demand performance-based data that documents an understanding, application, and implementation of quality improvement principles with regard to the services that they need and expect. Knowledge of and application of continuous quality improvement will be the only valued approach to health care change and survival in the future.  




1.Lighter,DE., Continuous Quality Improvement-What every physician leader needs to    know., in Stahl,MJ., Dean,PJ., The Physician’s Essential MBA. Aspen Publications,

Gaithersburg, Maryland, 1999. p.265

2.Lighter,DE.,ibid. p.268

3.Kongsvedt,PJ., The Managed Care Handbook. Aspen Publications,

Gaithersburg, Maryland.

4.Millenson, M., Demanding Medical Excellence, University of Chicago Press, Chicago, 1997

5.Kohn,LT., Corrigan,JM., Donaldson, MS. (eds), To Err is Human: building a safer health system., National Academy Press, Washington, D.C., 2000.

6.Committee on Quality Health care in America, Institute of Medicine, Crossing the Quality Chasm: a new health system for the 21st century., National Academy Press, Washington, D.C., 2001.

7.Audet,AM.,Hartman,EE., A 58-Year-Old Woman Dissatisfied With Her Care, 2 Years Later, JAMA 287(12):1577, 2002.

8. Lighter,DE.,ibid. p.268

9.Langley,GJ.,Nolan,KM.,Nolan,TW., Norman,CL., Provost,LP. The Improvement

   Guide., Jossey-Bass Publishers, San Francisco, California. 1996. P.xxiv

10.Millenson, M., ibid, p.248-252.

11.Ott, ER., Walter A. Shewhart, Father of statistical quality control.

www.asq.org/join/about/history/shewhart.html .

12.Bauer,JE.,Duffy,GL.,Wesstcott,RT(eds.), The Quality Improvement Handbook, Quality Press, Milwaukee, 2002.

13.Langely,GJ.,ibid. p.xxv

14.Langely,GJ.,ibid. p.xxvi

15.Deming,WE., Out of the Crisis. Cambridge: Massachusetts Institute of Technology,

     Center for Advanced Engineering Study, 1986.

16.Langely,GJ., ibid. p.xxvi

17.Langely,GJ., ibid. p.6

18.Langely,GJ., ibid. p.10

19.Bauer,JE., et al, ibid., pg 22-24.

20.Bauer,JE., et al, ibid., pg 24-26.

21.Cohen,BI., Florence Nightingale, Scientific American, 250(3):128-137.

22.Ulrich, BT., Leadership and Management According to Florence Nightingale, Norwalk, Appleton & Lange, 1992, pg. 2-6,10-58.

23.Donabedian,A., The End Results of Health Care. Ernest Codman’s Contribution to Quality Assessment and Beyond. The Millbank Quarterly, 67(2):233-234,1989.

24.Neuhauser, D., Heroes and Martyrs of Quality and Safety: Ernest Amory Codman MD., Qual Saf Health care 11:104-105,2002.

25.Batalden, PB., Biographical Sketch, Avedis Donabedian., personal communication in Curriculum Coursepack, Department of Veterans Affairs, National Quality Scholars Fellowship Program, Volume One (A), July 20, 2001.

26.Donabedian,A., Evaluating the Quality of Medical Care, Millbank Memorial Fund Quaterly, 44:166-206,1966.

27.Wilson,L., Goldschmidt,P., Quality Management in Health Care, McGraw Hill, New York, 1995, pg. 237-238.

28. Lighter,DE., ibid. p.273

29. Lighter,DE., ibid. p.273

30. SPSS, Version 9.0, 1998. chart display

31. Slavin,L., Best,MA., Aron, DC., Gone but not forgotten: The search for the lost surgical specimens: Application of quality improvement techniques in reducing medical error., Qual Mgmt in Hlth Care, 10(1):45-53,2001.

32. Nelson EC., Batalden, PB., Plume, SK., Mihevc, NT., Swartz, WG., Report Cards or  Instrument Panels, Journal on Quality Improvement, 21(4):155-166,1995.

33. www.cga.state.ct.us/2000/rpt/olr/htm/2000-r-1053.htm#topofpage .

34. www.ncqa.org/Programs/HEDIS/

35. Plsek, PE., Greenhalgh,T., The Challenge of Complexity in Health Care.,

      BMJ 323:625-628,2001.

36.Veterans Administration National Center of Patient Safety (NCPS), Patient Safety Improvement Training Manual, Ann Arbor, p.22, 2002.

37.VA NCPS, NCPS Triage Cards ™ for Root Cause Analysis, http://vaww.ncps.med.va.gov/ .

38.Burton Houle, T., Field Guide to the Theory of Constraints Thinking Process,

Avraham Y. Goldratt Institute, 2001.

39.Frendendall, LD., Patterson, JW., Lenhartz, C., Mitchell, BC., What Should Be Changed? A comparison of cause and effect diagrams and current reality trees shows which will bring optimum results when making improvements. Quality Progress, January, 2002, p50-59, available at http://www.asq.org/ .

40.Nave, D., How to Compare Six Sigma, Lean and the Theory of Constraints: A framework for choosing what’s best for your organization. Quality Progress, March, 2002, P 73-78.

41.Seecof, D., Applying the Six Sigma Approach to Patient Care., Six Sigma for Healthcare, Volume 2, Issue 5, May, 2000, www.gemedicalsystems.com/prod_sol/hcare/resources/insights/mins0500.html .

42.Pougnet,T., Ricard, M., Zollinger-Read, P., Lean Thinking: From the assembly line to the Emergency Room., http://ihi.org/conferences/natforum/handouts/D21_I.pdf

43.Bauer,JE., et al, ibid., pg 30-32.

44.Ketola J., Roberts, K., Demystifying ISO 9001:2000, Quality Progress, September, 2001, Pg. 65-70.

45.Bauer,JE., et al, ibid., pg 32-33.

46.Weick KE., Sutcliffe, KM., Managing the Unexpected: Assuring High Performance in an Age of Complexity, Jossey-Bass, San Francisco, 2001, http://www.josseybass.com/ .

47.Dalen, JE., Health Care in America: The good, the bad, and the ugly., Arch Intern Med, 160:2573-2576,2000.

48.Lovern, E., ‘Wave of the future’: Leapfrog’s release of hospital information sets off swell of activity., Modern Healthcare, January 21, 2002, http://www.modernhealthcare.com/ .

49.Hawkins, JA, JCAHO/Leapfrog Group Join Forces., The Physician Executive, March-April, 2002, pg. 7, http://www.acpe.org/ .

50. www.bristol-inquiry.org.uk/index.htm .

51. Spath, PL.,(ed.), Error Reduction in Health Care: A systems approach in improving patient safety., Jossey-Bass, San Francisco, 2000, http://www.jossey.bass.com/ .

52.Reason, J., Human Error, Cambridge University Press, Cambridge, 1990.

53.Berwick, DM., Godfrey, AB., Roessner, J., Curing Health Care-New Strategies for Quality Improvement., Jossey-Bass, San Francisco, 1990, http://www.jossey-bass.com/ .

54.Nelson, EC., Batalden, PB., Mohr, JJ., Plume, SK., Building a Quality Future., Frontiers of Health Services Management., 15(1):3-32,1998.

55.Coye, MJ., No Toyotas in Health care: Why medical care has not evolved to meet patients’ needs., Health Affairs, 20(6):44-56,2001.

56.VHA Staff, The Business case for Quality., 2000 Research Series, Volume 1, www.vha.com/prodserv_bcfq.pdf .

57.VHA Staff, Consumer Demand for Clinical Quality: The Giant Awakens., 2000 Research Series, Volume 3, www.vha.com/prodserv_consumer.pdf .


Other Reading Resources:

*Crosby PB, Quality is Free: The art of making quality certain, Mentor, New York, 1980.

*Tague, NR., The Quality Toolbox., ASQ Quality Press, Milwaukee, 1995.

*Carey,RG., Lloyd, RC., Measuring Quality Improvement in Healthcare: A guide to statistical Process Control Applications., ASQ Quality Press, Milwaukee, 2001.

*Goldratt EM and Jeff Cox, The Goal: A process of ongoing improvement (2nd ed),  North River Press, Great Barrington, 1992, http://www.northriverpress.com/ .

*Chowdhury S., The Power of Six Sigma, Dearborn Trade, Chicago, 2001, http://www.dearborntrade.com/ .



http://www.iom.edu/  - more information about the Institute of Medicine of the National Academy of Sciences


http://www.nap.edu/  - the full text of the report To Err is Human, and The Quality Chasm is available online from this site.


www.juran.com/research/back_articles.html - more information about the current programs at the Juran Institute, including Six Sigma.


www.philipcrosby.com/main.htm - more information about the ongoing work at Philip Crosby and Associates.


www.jcaho.org/mainmenu.html  - more information about the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Originators of the Codman Awards.


http://www.ncqa.org/index.htm - more information about the National Committee for Quality Assurance, a not-for-profit watchdog organization for the managed care industry.


http://www.quality.nist.gov/ - for more information about the Baldrige Award.


www.iso.ch/iso/en/ISOOnline.frontpage - more information about ISO 9000.


http://www.asq.org/ - the American Society for Quality home page, a useful site to learn practical lessons and gain insight into current knowledge about quality through access to Quality Progress articles referenced above.


http://www.gemedicalsystems.com/ - more information about six sigma applications for healthcare as researched and published by General Electric Medical Systems.


http://www.patientsafety.gov/  - a website for resources from the National Center for Patient Safety (NCPS). Including root cause analysis information. The Veterans Administration NCPS is a winner of the 2001 Innovations in American Government Award.


(Access to all of the above links verified as of 4.13.2002)