M Best

Avedis Donabedian: father of quality assurance and poet

A vedis Donabedian was born in Beirut, Lebanon on 7 January 1919. As a child he moved to a small town near Jerusalem in Palestine (now Israel) after his family fled the Armenian holocaust. However, in Palestine he experienced the social turmoil of that region. Although a Christian, he had Jewish, Arab, and Christian friends as he was growing up in Palestine. At the interpersonal level he was able to circumvent social and political obstacles. Years later Donabedian attended the American University of Beirut where he received a BA degree in 1940 and an MD degree in 1944. He served as a general practitioner physician in Jerusalem and Beirut until 1954 when he moved to Boston. In 1955 he graduated from the Harvard School of Public Health with an MPH degree (magna cum laude). He taught preventive medicine at the New York Medical College from 1957 to 1961. The School of Public Health at The University of Michigan recruited him in 1961, and he remained there for 28 years. In 1979 he was honored as the Nathan Sinai Distinguished Professor of Public Health at the University of Michigan in recognition of his contributions in public health. He retired in 1989 but continued to serve as emeritus professor until his death on 9 November 2000 after a 28 year battle with prostate cancer.

Gone but not forgotten: the search for the lost surgical specimens: application of quality improvement techniques in reducing medical error.

Abstract A lost surgical specimen prompted an investigation of both the human processes and the systemic factors involved in surgical specimen handling regarding how health care organizations approach medical error prevention and patient safety promotion. Quality improvement techniques and the conceptual error model of James Reasons were employed to understand the interaction between the local process of specimen handling and the systemic influences to medical error management. Error management recognizes the inevitability of both individual and systemic error. Through the use of quality improvement techniques and models of error analysis, health care organizations can investigate the error potential of health care delivery and address the human and organizational interaction necessary to improve patient safety and manage medical error.

Making the right decision: Benjamin Franklin’s son dies of smallpox in 1736

Benjamin Franklin in his autobiography said: > “In 1736 I lost one of my sons, a fine boy of four years old, by the smallpox taken in the common way. I long regretted bitterly and still regret that I had not given it to him by inoculation. This I mention for the sake of the parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”1 Good medical care requires making the right decisions—to test, treat or do nothing—in the face of uncertainty.2 Franklin came to believe he made the wrong decision to forgo smallpox inoculation for his son in 1736. We have enough information about Franklin’s decision, made over a quarter of a millennium ago, to evaluate his choice. Benjamin Franklin was born in Boston in 1706. He worked as an apprentice to his brother James in a printing business in 1716 before moving to Philadelphia in 1723.34 During this era smallpox came periodically to these isolated commercial towns perhaps by way of an infected person on a merchant ship and swept through the town. Those who had been infected in the past and survived were immune. Most of the rest took smallpox “in the natural way” and lived or died from it. A few escaped the contagion all together. For about a decade afterwards, the town was immune to smallpox. A new generation of children were born and new people moved in. With time the unprotected proportion of the population grew. With each passing year without smallpox the risk of a new epidemic grew greater and the cycle would repeat itself. Boston had such epidemics in …

Did a cowboy rodeo champion create the best theory of quality improvement? Malcolm Baldrige and his award.

The Baldrige Award criteria are an excellent example of the practical application of Quality Improvement theory and are named for Malcolm Baldrige (1922 to 1987). They are the all-industry quality prize of the USA and are analogous to the Deming Prize of Japan, which was started in 1951. This award is a central feature of what is now called the Baldrige Performance Excellence Program. Malcolm Baldrige was born in Omaha, Nebraska in 1922. His father was H Malcolm Baldrige, a Nebraska lawyer and congressman. He was educated at Yale University, and received a bachelors degree in 1944. In 1945, he fought in World War II at the battle of Okinawa. He married Margaret T Murrary in 1951, and they went on to have two daughters. As a boy, he worked as a ranch hand and became very skilled at roping. He went on to become a member of the Rodeo Cowboys Association, was Professional Rodeo Man of the Year in 1980 and was elected into the National Cowboy Hall of Fame in 1984. He went to work at a Connecticut factory as a labourer and became its president and a successful businessman. President Ronald Reagan nominated Baldrige to be the 26th Secretary of Commerce on 11 December 1980. During his tenure, he reduced his Commerce Department budget by over 30% and was noted for his managerial excellence. He played a major role in reforming antitrust laws, and in forming US trade policy with China, India and the Soviet Union. Baldrige was in a rodeo accident that led to his untimely death on 25 July 1987.1 On 6 January 1987, Congress passed the ‘Malcolm Baldrige National Quality Improvement Act of 1987’ and later, on 20 August 1987, President Ronald Reagan approved the Act and signed it into law (Public Law …

Kaoru Ishikawa: from fishbones to world peace

> In management, the first concern of the company is the happiness of the people connected with it. If people do not feel happy and cannot be made happy, that company does not deserve to exist. (Kaoru Ishikawa1) Today, Kaoru Ishikawa is best known for his diagram which looks like the bones of a fish. His diagram is a practical widely used tool for a group to organise its understanding of the causes of variation in the outcome of their work. He was an unassuming man who saw a link between workplace quality and prosperity. High-quality products would sell, and their makers would prosper. If work was thus made a joyful and human experience, such prosperity and joy would lead to world peace. Some might find this vision grandiose, but Ishikawa was as responsible as anyone for transforming Japanese industry after the Second World War to focus on high-quality products. This lead to a prosperous, peaceful Japan. The Japanese quality revolution woke up the rest of the industrial world. Ishikawa believed that quality began with the interaction of people. Top-down (goals) and bottom-up (means) involvement by all members of an organisation is required to optimise quality. Pulling out employee potential is a key leadership skill. Enhancing the quality of life of people enhances the quality of outcomes and productivity of their services. Happy people are more productive and have more pride and responsibility for their work. Ishikawa was one of the first people to emphasise the “internal customer.” Kaoru Ishikawa was born in Tokyo, Japan, the eldest of eight brothers. His father invited Deming to Japan. In 1939, he was granted a doctorate of philosophy in chemical engineering by the University of Tokyo. He worked as a naval technical officer from 1939 to 1941, then at the Nissan Liquid …

Gone but not forgotten: The search for the lost surgical specimens: Application of quality improvement techniques in reducing medical error

A lost surgical specimen prompted an investigation of both the human processes and the systemic factors involved in surgical specimen handling regarding how health care organizations approach medical error prevention and patient safety promotion. Quality improvement techniques and the conceptual error model of James Reasons were employed to understand the interaction between the local process of specimen handling and the systemic influences to medical error management. Error management recognizes the inevitability of both individual and systemic error. Through the use of quality improvement techniques and models of error analysis, health care organizations can investigate the error potential of health care delivery and address the human and organizational interaction necessary to improve patient safety and manage medical error.

Osler Peterson MD watches the practice of medicine

A century ago this year, the Flexner Report of 1910 described the largely deplorable state of American medical education.1 The Rockefeller Foundation spent decades and a lot of money improving these schools.2 Those schools that did not meet the new standards closed their doors. By 1950 the Foundation leadership asked themselves if their successful efforts to improve education had, by then, actually changed the real practice of medicine for average Americans. It was decided that Osler Peterson was the person to go and see. Osler Peterson MD was, at the time, on the Rockefeller Foundation staff. He was seconded to the University of North Carolina where he undertook to watch the actual practice of medical care provided by a sample of 102 primary care doctors in that state in order to judge the quality of care they were providing. He and his colleagues reported their observations in a special supplement in 1956, of the Journal of Medical Education .3 As a result, this mild, curious, scholarly man made a lot of enemies among these practitioners. However, in later years, and in spite of this experience, he was willing to take on organised medicine over national health insurance and the American surgical establishment. Osler Peterson must have appeared an odd duck to these practitioners, but letters of introduction, being a physician and southern courtesy opened these doors. The doctors were interviewed, their medical school grades obtained, offices visited and their practice watched by observers who, as physicians, knew what they were observing. This is not a low-cost data-collection method, which is one reason it is so rarely done. Each practice was given a grade on a five-point scale of quality. Eighty-eight practices were actually observed. The observations were grouped into six domains: clinical history, physical examination, use of …