Quality improvement projectsin health care

By Eleanor GilpatrickSage 390 pages£21

Has the passion for quality improvement passed its zenith? We don't seem to hear as much about it as we did five years ago. There could be two reasons: either total quality management and its kind have passed into the culture, or the fad has given way to something else such as managed care.

One way to check how far quality improvement is now part of our system is to read a comprehensive text such as this one. The other way is simply to visit your local hospital.

This book, for all its painstaking exposition, suffers like some other US literature from an inability to accept that its readers will already have some basic knowledge.

For instance, it majors on definitions. We are told that a solution is: 'Change that addresses a cause so that the problem is eliminated or reduced.' Wow!

So is it worth wading through the text at all? The context is the US and there appear to be no references to more international writing on the subject. The 240 pages of case studies, to be fair, cover universal situations, including waiting times, excessive length of stay, recording errors and poor staff performance.

The format is highly structured. The opening chapter concerns principles and concepts and includes a useful account of the changes in methods which the US Joint Commission on Accreditation of Healthcare Organisations has adopted in the past 10 years, moving from checking preordained standards towards evaluating outcome measures.

The next four chapters help the reader to check if the problem actually exists, how to verify its causes, and offer suggestions on how to find and implement solutions.

Each chapter is clearly set out, with tables illustrating the approaches that are further investigated in a laborious fashion in the case studies.

For the UK reader the problem is not context - because we can easily adapt - but the basic approach to learning.

Do we really learn in this quasi-scientific manner using the sequential rational model we all learned on our first management courses? It is here assumed that provided you work painstakingly through the process you will get there in the end.

The fact that the NHS still does not operate at all smoothly on many occasions suggests that we do not understand the real causes of the trouble. Elaborating the process of quality improvement may only compound the problem.

I'm afraid a book such as this, specifically addressed to middle managers and their supervisors, will do little to penetrate the central mystery in organisations: why won't people do things properly even when they know how?

Ms Gilpatrick has some insight into this basic conundrum, but not enough to recommend you rush out and buy her book.

Andrew Wall