Mohammed M A, Cheng K K, Rouse A, Marshall T
Department of Surgery, University of Birmingham, Edgbaston, UK.
Lancet. 2001 Feb 10;357(9254):463-7. doi: 10.1016/s0140-6736(00)04019-8.
During the past century, manufacturing industry has achieved great success in improving the quality of its products. An essential factor in this success has been the use of Walter A Shewhart's pioneering work in the economic control of variation, which culminated in the development of a simple yet powerful graphical method known as the control chart. This chart classifies variation as having a common cause or special cause and thus guides the user to the most appropriate action to effect improvement. Using six case studies, including the excess deaths after paediatric cardiac surgery seen in Bristol, UK, and the activities of general practitioner turned murderer Harold Shipman, we show a central role for Shewhart's approach in turning the rhetoric of clinical governance into a reality.
在过去的一个世纪里，制造业在提高产品质量方面取得了巨大成功。这一成功的一个关键因素是运用了沃尔特·A·休哈特在经济控制变异方面的开创性工作，这项工作最终促成了一种简单却强大的图形方法——控制图的发展。该图表将变异分为有共同原因或特殊原因两类，从而引导使用者采取最恰当的行动来实现改进。通过六个案例研究，包括英国布里斯托尔小儿心脏手术后的超额死亡案例以及全科医生转行成为杀人犯的哈罗德·希普曼的行为，我们展示了休哈特方法在将临床治理的言辞转化为现实方面所发挥的核心作用。
