These pages discuss
some of the organizational and pragmatic issues associated with developing a
quality control program. Also see Category: Analysis of means, Category: Control charts.
Other entries about quality control can be found in the
quality control page at the
StATS website.
2010
- P.Mean: Examples of a fishbone diagram
(created 2006-03-24, revised 2010-06-29). This is an update of a webpage
originally published at http://www.childrens-mercy.org/stats/weblog2006/FishboneDiagram.asp.
The fishbone diagram (also called the Ishikawa diagram, or the case and effect
diagram) is a tool for identifying the root causes of quality problems. It was
named after Kaoru Ishikawa, the man who pioneered the use of this chart in
quality improvement in the 1960's. Surprisingly, I have had to hunt very hard
to find any good examples of a fishbone diagram.
Other resources:
- US Navy Total Quality Leadership Office. Basic Tools for Process
Improvement: Cause-and-Effect Diagram [PDF]. This website is cited in
Category: QualityControl. Description:
This website offers simple explanations of the cause and effect diagram, a
classic tool used in quality improvement. This same guide is also found at
www.management-tools.org/files/c-ediag.pdf and www.saferpak.com/cause_effect_articles/howto_cause_effect.pdf.
Other guides are available at www.hq.navy.mil/RBA/text/tools.html. This
website was last verified on 2006-03-24. URL:
www.hq.navy.mil/RBA/c-ediag.pdf.
- Gary Wolf. The Data-Driven Life. The New York Times. 2010.
Excerpt: "And yet, almost imperceptibly, numbers are infiltrating the last
redoubts of the personal. Sleep, exercise, sex, food, mood, location,
alertness, productivity, even spiritual well-being are being tracked and
measured, shared and displayed. On MedHelp, one of the largest Internet
forums for health information, more than 30,000 new personal tracking
projects are started by users every month. Foursquare, a geo-tracking
application with about one million users, keeps a running tally of how many
times players “check in” at every locale, automatically building a detailed
diary of movements and habits; many users publish these data widely.
Nintendo’s Wii Fit, a device that allows players to stand on a platform,
play physical games, measure their body weight and compare their stats, has
sold more than 28 million units." [Accessed May 1, 2010]. Available at:
http://www.nytimes.com/2010/05/02/magazine/02self-measurement-t.html.
- Brian L. Joiner, Sue Reynard, Yukihiro Ando. Fourth generation
management. McGraw-Hill Professional; 1994. Excerpt: "I knew that it was
important to find better ways to do things and to eliminate waste and
inefficiencies; that data could shed light on murky situations; that people
needed to work together. But it took another 20 years working with large
companies and small, with government, service, and manufacturing
organizations, with top managers, with operators on the shop floor, before I
had a good understanding of how all these pieces fit into a system of
management that brings rapid learning and rapid improvement. It's a system
I've come to call 4th Generation Management." Available at:
http://books.google.com/books?id=E99OVbYUmhEC.
- Gaye P, Nelson D. Effective scale-up: avoiding the same old traps. Human
Resources for Health. 2009;7(1):2. Available at:
www.human-resources-health.com/content/7/1/2.
[Accessed February 24, 2009].
- Julie Weed. Factory Efficiency Comes to the Hospital. The New
York Times. 2010. Excerpt: "The program, called “continuous performance
improvement,” or C.P.I., examines every aspect of patients’ stays at the
hospital, from the time they arrive in the parking lot until they are
discharged, to see what could work better for them and their families. Last
year, amid rising health care expenses nationally, C.P.I. helped cut Seattle
Children’s costs per patient by 3.7 percent, for a total savings of $23
million, Mr. Hagan says. And as patient demand has grown in the last six
years, he estimates that the hospital avoided spending $180 million on
capital projects by using its facilities more efficiently. It served 38,000
patients last year, up from 27,000 in 2004, without expansion or adding
beds." [Accessed July 13, 2010]. Available at:
http://www.nytimes.com/2010/07/11/business/11seattle.html.
- David Leonhardt. Making Health Care Better. The New York Times.
November 8, 2009. Description: This article profiles Brent James. chief
quality officer at Intermountain Health Care, and his pioneering efforts to
rigorously apply evidence based medicine principles. It highlights some of
the quality improvement initiatives at Intermountain and documents the
resistance to change among many doctors at Intermountain. [Accessed
January 14, 2010]. Available at:
http://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html.
- Frank Davidoff, Paul Batalden, David Stevens, Greg Ogrinc, Sue Mooney,
Joy McAvoy, Leslie Walker. SQUIRE. Standards for
Quality Improvement Reporting Excellence.
Excerpt. The SQUIRE Guidelines help authors write excellent, usable
articles about quality improvement in healthcare so that their findings can
be easily discovered and widely disseminated, thus spreading improvement
work to a broader population. URL:
http://squire-statement.org/index.php.
- Denise Dougherty, Patrick H. Conway. The "3T's" Road Map to Transform
US Health Care: The "How" of High-Quality Care. 2008. Excerpt: "The
ongoing significant investment in basic science and clinical discovery in
the United States continues to produce impressive results. However, the
United States struggles to deliver high-quality care and improved health
outcomes due to the systematic failure of discoveries to reach patients in a
timely fashion.1-2 Despite expenditures that reached $2 trillion or more
than $6000 per capita in 2005,3 the United States will continue to fail to
fully leverage new clinical discoveries into improved health outcomes unless
there is an accelerated transformation of the health care system.4 The
research enterprise cannot achieve this alone. We propose a model to
transform the US health care system (Figure), intended to accelerate the
pace at which innovations are implemented in clinical settings by addressing
the "how" of health care delivery." [Accessed July 13, 2010]. Available
at:
http://jama.ama-assn.org/cgi/content/extract/299/19/2319.
All of the material above this paragraph is licensed under a
Creative Commons Attribution 3.0 United States License. This page was written by
Steve Simon and was last modified on
2010-07-12. The material
below this paragraph links to my
old website, StATS. Although I wrote all of the material
listed below, my ex-employer, Children's Mercy Hospital, has claimed copyright
ownership of this material. The brief excerpts shown here are included under
the fair use provisions of U.S. Copyright laws.
2008
2007
- Stats: What I'm working on
right now (March 18, 2007). There are several research projects where I
am actively looking for collaborators. I thought I'd outline these topics
briefly here.
- Stats: Handouts for quality
control workshop (March 2, 2007). I am in charge of a workshop for the
American Society for Andrology for their 32nd Annual Conference in Tampa
Florida. I am putting together some handouts for this workshop. These
handouts are consolidated in a single web page and an abbreviated version
will be included in the packet that students receive: Stats #18: Quality
Control: A Hands-On Workshop, and Stats #18: Quality Control: A Hands-On
Workshop (condensed version).
- Stats: Three simple rules to
establish quality (February 15, 2007). I received a recommendation to
purchase a book (Process Quality Control, by Ellis Ott) and while searching
for reviews of this book, found something called Ott's Rules. These are three
simple rules advocated by Dr. Ott in any process control problem:
2006
- Stats: A plea for open
mindedness (November 2, 2006). Most people that I work with are quite
open minded, but I do encounter, from time to time, someone who is resistant
to ideas that originate from outside the sphere of medicine. In particular,
some individuals are almost cynical about the application of quality control
in health care. The attitude seems to be something like this: Quality
control is an approach that works on assembly lines. I'm a doctor not a
factory worker, and my patients are not products on an assembly line.
That's a fair statement. Patients are not widgets, and it is a mistake to
treat them the same way. But it's also a mistake to think that we can't learn
from how other people have approached problems that do indeed bear some
semblance of similarity to the problems that you face.
- Stats: Resources for the use of
Statistical Process Control in Healthcare (September 15, 2006). Someone
on the MedStats email discussion group asked for resources that "explain the
use of SPC (statistical process control) to analyze quality indicators in a
healthcare organization." I'm working on some research grants to use control
charts to provide guidance to continuing review and monitoring of clinical
trials. The most recent page that discusses this is at: Stats: My second
grant, part 2 (Model, Quality, September 13, 2006). I also may end up giving
a talk for PharmaIQ, a division of the International Quality & Productivity
Center (IQPC), and they look to have a lot of interesting conferences on
healthcare and quality. Of course, my opinion is probably biased by the
belief that any group that invites me to talk must have a good appreciation
of talent. The Healthcare IQ section actually looks to be quite interesting.
There's a lot out there, and this is only a partial list. I tried to include
only those resources that had a direct link to health care, with the
exception of Donald Wheeler's book, which is a worthwhile read for anyone in
any discipline.
- Stats: Quality control
humor (August 20, 2006). It is important in any quality improvement
process to define precisely what it is that you are trying to improve. Sloppy
and imprecise definitions will make it hard for you to measure your process,
much less improve it. But sometimes this effort to define things can go to
far, as illustrated in this cute story on rec.humor.funny.
- Stats: Examples of Pareto charts
(April 5, 2006). The Pareto chart is a graphical display of categorical
data that is intended to show the relative frequency of different events that
all impact the quality of a process. The graph is typically drawn to examine
the Pareto principle, also known as the 80-20 principle. The Pareto
principle, which does not always work in the real world, but occurs often
enough to merit its own name, says that 80% of the problems in a system can
be attributed to 20% of the causes. There are applications in other areas as
well (80% of the wealth in a country might be held by the richest 20% of the
population, for example). The 80-20 split might actually be closer to 90-10
in some situations, or perhaps closer to 70-30 in other situations. Still it
is worth remembering the a very few things in your workplace are responsible
for most of your quality problems.
- Stats: Examples of a fishbone
diagram (March 24, 2006). The fishbone diagram (also called the Ishikawa
diagram, or the case and effect diagram) is a tool for identifying the root
causes of quality problems. It was named after Kaoru Ishikawa, the man who
pioneered the use of this chart in quality improvement in the 1960's.
Surprisingly, I have had to hunt very hard to find any good examples of a
fishbone diagram.
- Stats: Davis Balestracci
seminar (January 19, 2006). A couple of people I work with are very
interested in applying quality control in various processes at Children's
Mercy Hospital. We already have a quality improvement program in place, but
these folks want to incorporate some ideas they learned after attending a
seminar by Davis Balestracci at the Institute for Healthcare Improvement
annual forum. I was unfamiliar with Mr. Balestracci's work, but he has a very
nice website (www.dbharmony.com) that discusses many of the left brain
(analytic/rational) and right brain (emotional/intuitive) issues associated
with implementing a quality program.
2005
- Stats: Quality
control exercises, Part 2 (October 5, 2005). I tried a pilot experiment
of a quality control exercise. It seemed to go fairly well. The goal of the
exercise was to flip a coin from a table onto a target on the floor below.
- Stats: Quality control
exercises (September 1, 2005). I've taught several courses on Quality
Control, and the best part is the practice exercises. At the American Society
of Andrology's lab workshop in 2005, I used a blind paper cutting exercise
described in Stone, Richard A. (1998) The blind paper cutter: Teaching about
variation, bias, stability, and process control. The American Statistician,
52, 244-247. It worked very well, and I wanted to use it again for the 2006
workshop. But unfortunately, many of the people attending the new workshop
will have attended the previous workshop. So I have to find a new practice
exercise.
- Stats: Tolerance limits (April
15, 2005). Someone asked me about the difference between control limits
and tolerance limits. I have a web page about quality control models that
talks a bit about control limits for a control chart. The word "tolerance" is
ambiguous and could mean several things. There is a formal tolerance interval
which is a confidence interval for percentile limits of a distribution. In
another context, tolerance limit might represent an engineering
specification, where values inside the limit represent parts that will work
reliably in the machine or product.
- Stats: Taguchi methods (February
22, 2005). Genichi Taguchi was a Japanese engineer and statistician who
developed a wide range of statistical tools for improving the quality of
industrial manufacturing. These tools are collectively known as Taguchi
methods.
2004
- Stats: Quality control in the
laboratory (March 9, 2004). I'll be giving a talk at the American Society
for Andrology in April about the use of quality control for sperm morphology
assessments. I'll put some of my notes up on the web when I get the chance.
What now?
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