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Evaluating the processes of neonatal intensive care: thinking upstream to improve downstream outcomes
  1. E M Boyle

    Statistics from

    Edited by Joseph Schulman. London: BMJ Books, 2004, £20.00, pp 145. ISBN 0 7279 1833 8

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    This book tackles the issue of quality of care from a rather different angle, challenging the reader to examine and optimise the processes involved in neonatal intensive care rather than focusing solely on individual outcomes. It seeks to unravel the complex interplay between the many different components that contribute, directly or indirectly, to patient care. The book centres on the view that changes will only come about if we acknowledge that the neonatal unit and the people and activities within it function not in isolation, but within the context of a much larger system. Likewise, within the confines of the unit itself, a multitude of smaller systems operate together to produce what we have come to recognise as good patient care. It is the interrelationships between these systems that determine the effectiveness and quality of the care given. Likening the “system” of the neonatal unit to a production system, the author uses the methods successfully adopted by Japanese car manufacturers to illustrate ways in which this can be approached to improve quality and “customer service”. At first sight, this may seem an inappropriate comparison, but the author convincingly outlines a number of parallels between the two.

    A number of the methods suggested for improving the process of care seem obvious and appeal to a common-sense approach. However, there can be few who would not welcome simple and effective ways of avoiding unnecessary activities and achieving motivation of staff! The author stresses the importance of understanding the processes of care before we can successfully evaluate them. He then aims to equip the reader with the necessary tools to collect, analyse, summarise, and present data. Some methods covered, such as the use of sensitivity, specificity, and receiver operating characteristic curves in evaluation of diagnostic testing will be familiar to many readers. Others, for example process mapping to break down a care process into bite-size components, Pareto diagrams to illustrate relative importance of problems encountered, and control charts may be techniques that have not been encountered previously. The specific techniques are explained clearly, using examples that are, for the most part, easy to follow. One could imagine being able to use them as adjuncts to the more familiar analytical and statistical methods. Recognising that change for the better cannot be achieved by analysis alone, but relies heavily on the personnel involved in implementation, the author helpfully devotes some time to this towards the end of the book. Lastly, a checklist summarising some of the book’s important points is a useful addition as an appendix.

    The book is short and easy to read, with a layout that is logical and accessible. Its style is friendly and chatty, if bordering on the patronising at times. The recurrent use of Japanese terminology can become rather tedious, but does not detract from the book’s content, which is interesting and useful. It will be of particular interest to those whose work involves the organisation of data collection and analysis for clinical audit, governance, benchmarking, and research. However, any clinician who wishes to develop a deeper interest in the evaluation of care will find this book stimulating and informative.

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