Davidoff F. Heterogenity is not always noise: Lessons from improvement. Journal of the American Medical Association. 2009 Dec;302(23):2580-2586.

Rigorous experimental methods suppress differences among study participants (noise) to detect true intervention effects (signals). But suppressing participants' heterogeneity obscures an essential dimension of biological and clinical knowledge. Medicine is therefore ambivalent about the influence of heterogeneity on outcomes and struggles to find ways to take it properly into account in both clinical practice and research. This analysis explores the roots of that ambivalence.

Berwick DM. Measuring physicians' quality and performance: Adrift in Lake Wobegon. Journal of the American Medical Association. 2009 Dec 9;302(22):2485-2486.

This editorial comments on a study that looked at the relationship of primary care physicians' Medicare patient caseload with measurements of physician quality and cost performance. The study concluded that relatively few practices are large enough to reliably measure differences in these key dimensions. Dr. Berwick offers suggestions for defining systemic measures of practice performance that can yield meaningful data from which we can all learn.

Lloyd RC, Goldmann DA. A matter of time. Journal of the American Medical Association. 2009 Aug 26;302(8):894-895.

In this commentary, a new perspective on time — improvement time — is discussed in the context of three traditional aspects of medical time: clinical research (knowledge) time, patient (illness) time, and clinical practice (disease) time.

Gray JR, Berwick DM. Peering into the chasm: Improving the quality of clinical genetic services. American Journal of Medical Genetics: Part C, Seminars in Medical Genetics. 2009 Aug 15;151C(3):173-174.

Other specialties in the US and elsewhere are rapidly adopting the potent combination of measurement, transparency, and continuous, collaborative learning and improvement. The authors suggest that clinical genetics should also adopt these elements, including mapping clinical genetics services to the six aims for improvement articulated in the Institute of Medicine Crossing the Quality Chasm report. Such scrutiny will reveal both the strengths and the weaknesses of providing clinical genetics care to patients.

Fine AM, Kalish LA, Forbes P, Goldmann D, Mandl KD, Porter SC. Parent-driven technology for decision support in pediatric emergency care. Joint Commission Journal on Quality and Patient Safety. 2009 Jun;35(6):307-315.

The purpose of this study was to determine if parent-driven health information technology (HIT) influenced completeness of documentation and adherence to evidence-based emergency care for children. Parent-driven HIT suggested a trend toward modest impact on pain management but did not demonstrate broad effects across diseases or care processes. The personally controlled health record presents opportunities for incorporating parent-derived information into medical decision making.

Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP
San Francisco, California, USA: Jossey-Bass Publishers; 2009

The Model for Improvement, an integrated approach to process improvement that delivers quick and substantial results in quality and productivity in diverse settings, is explored. This updated edition includes new information on accelerating improvement by spreading changes across multiple sites. A practical tool kit of ideas and examples from diverse industries, including health care, and international improvement efforts are shared.

Berwick DM. The epitaph of profession. British Journal of General Practice. Advance online publication. 25 Nov 2008; DOI: 10.3399/bjgp08X376438.

In an October 2008 address to the Royal College of General Practitioners in the UK, Dr. Donald Berwick makes observations about the changing medical profession by reflecting on his father's career as a physician in rural Connecticut. He describes the attitudes, skills, and knowledge that the "new professional" must have.

Godfrey MM, Melin CN, Muething SE, Batalden PB, Nelson EC. Clinical microsystems, part 3: Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies. Joint Commission Journal on Quality and Patient Safety. 2008 Oct;34(10):591-603.

This article describes how two hospitals — a large, urban academic medical center and a rural, community hospital — chose a similar microsystem-based approach to improvement, customizing the engagement and the improvement targets on the basis of an understanding of the local context. The authors conclude that their improvement experience suggests tips and actions at all levels of the organization that could be adapted with specific context knowledge by others.

Berwick DM. Escape Fire: Lessons for the Future of Health Care. New York, New York: The Commonwealth Fund; November 2002.

This monograph presents the December 9, 1999, “Escape Fire” keynote address by IHI President and CEO Dr. Donald M. Berwick at IHI’s 11th Annual National Forum on Quality Improvement in Health Care, in which he describes a 1949 wildfire that broke out on a Montana hillside, taking the lives of 13 young men and changing the way firefighting was managed in the United States. Dr. Berwick applies the lessons learned from this catastrophe to the health care system and outlines an ambitious program for reform, what Berwick calls an "escape fire," the term firefighters use for a deliberately burnt patch of land that, in an emergency, can provide refuge from an oncoming blaze.

Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney SE; for the SQUIRE development group. Publication guidelines for quality improvement in health care: Evolution of the SQUIRE project. Quality and Safety in Health Care. 2008 Oct;17(Suppl 1):i3-i9.

In 2005, draft guidelines were published for reporting studies of health care quality improvement interventions. This article contains the full revised version of the guidelines, which the authors refer to as SQUIRE (Standards for QUality Improvement Reporting Excellence). Also see the accompanying Explanation and Elaboration article. [Learn more on the SQUIRE Guidelines website.]