- Email: [email protected]
Quality improvement in hand therapy
(
G~EST EDITORIAL J
Quality Improvement in Hand Therapy Peter C. Amadio, MD Associate Professor of Orthopaedic Surgery, M ayo Medical School; Consultant in Orthopaedics, M ayo Clinic, Rochester, Minnesota
and therapy, like hand surgery, began to
H organize as a defined area of special interest after World War II, primarily as a result of the hand centers that were established at military hospitals around the United States by Sterling Bunnell. 1,2 The young staff of those centers, taught by Bunnell, organized shortly after World War II to form the American Society for Surgery of the Hand . By the early 1970s, hand surgery was an acknowledged specialty.3 The American Society for Surgery of the Hand was widely recognized for its educational activities, and hand surgeons began efforts to form a board, or at least obtain board-level recognition in the form of a qualifying examination, for hand surgery, as a way of establishing minimum standards in hand surgery. 3 In 1989, the American Boards of Orthopedic Surgery and General Surgery offered the first certificate of added qualifications in hand surgery. In 1990, the American Board of Plastic Surgery also began to offer a certificate of added qualifications in hand surgery. In 1978 the American Society for Hand Therapists was formed and without delay began similar
Correspondence and reprint requests to Peter C. Amadio, MD, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905.
educational efforts. Hand therapists have moved with even greater speed in establishing a certifying examination. In May 1991, the Hand Therapy Certification Commission offered its first certifying examination in hand therapy. What is next? Is certification of minimum qualifications enotIgh? And if the provider must meet minimum standards, what about the services provided? Among the smorgasbord of health care offerings available, what services are of proven clinical benefit? How does the patient distinguish sham and hype from clinical truth? How will insurance companies decide to reimburse, for example, hand therapy services? All medical providers must deal with such issues. In the past, patients and insurers were considered by some medical providers to be a combination of golden goose and ostrich, creatures with their heads in the sand happily providing golden eggs, no questions asked, to the awaiting practitioner (Fig. 1).4 Those days are past. Instead, what we hear today are calls to justify what we do: practice guidelines, standards of care, clinical policies, and the like. L5,6 Whether we like it or not, we are being held accountable for our actions. We may choose to be observers and let others make the rules, but as professionals that is nota choice. With vocation comes October-December 1991
155
----~----
FIGURE 1. The Back Bay Golden Goose Ostrich, as seen by Codman. From: Codman fA: The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, 1934, p. XXVI.
responsibility. Furthermore, the drive and initiative of ASHT makes such a passive stance inconceivable. ASHT has been and should continue to be a leader in defining the place of hand therapy in clinical practice. These problems are by no means new. They were all reviewed nearly a century ago by a remarkably original thinker: the surgeon Ernest Amory Codman. Codman was born to wealth and privilege in the Boston high society of the late 19th century. He was rather eccentric, and managed to antagonize most of his contemporaries,? but he also accomplished a number of great things. He was among the first to correctly diagnose and treat appendicitis and duodenal ulcer. 4 He produced the first radiographic monograph on scaphoid fractures. 4 He was a founder of the American College of Surgeons. 4 He helped organize what is now the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).8 He helped organize a tumor registry, which was a forerunner of the American Cancer Society. 4 He wrote the first textbook on shoulder disorders.4 Lastly, and the topic of this paper, he fought vigorously all his life for what he called the End Result Idea. This idea so consumed him that one of his main purposes in writing his shoulder textbook was actually to gain wider circulation for his End Result concept (Fig. 2).4 This concept was explained in a 40-page autobiographical prologue (complete with a graphic display of his life, including even such details as the names and life spans of all his pet dogs) and a 30-page epilogue to the shoulder text. As if that were not enough, each book came with a four-page insert further expanding on the benefits of the End Result Idea. The End Result Idea is simple, yet profound. It has yet to be completely adopted by medicine in practice, although most accept it in theory. His End 156
JOURNAL OF HAND THERAPY
FIGURE 2. The fnd Result Idea banner, held aloft by the Shoulder balloon. From: Codman fA: The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa (epilogue). Boston, 1934, p. 29.
Result Idea is "merely the common sense notion that every hospital [substitute health care provider for 1990s relevance] should follow every patient it treats long enough to determine whether or not the treatment has been successful and then to inquire "if not, why not," with a view of preventing a similar failure in the future."4 All the hallmarks of modern quality improvement measures are there. 9 1t is inclusive (every
patient) and comprehensive (long enough) and it calls for defined goals and outcomes (whether or not treatment has been successful) with analysis and feedback (if not, why not). In individual practitioner terms we can ask "Why is our quality ever suboptimal? Why is time wasted? Why does work need to be done over? Why is data lost or not collected? Is it our skill, judgment, knowledge, equipment, or facilities? Is it something to do with our patients' diseases or the social conditions in which they live? Are other causes involved? Of course many of these issues are addressed individually in clinical research, but it is their integration, in the End Result Idea, that leads most readily to improvements in the care we provide. I'ndeed, Codman's Committee on Hospital Standardization8 (now the JCAHO) and his tumor registry were designed by him specifically to put in action the End Result Idea. He and the other founders of the American College of Surgeons considered the End Result "tail" more important than the College "dog," and felt the creation of the latter was needed to promote the former. 4 Nowadays the End Result Idea is mostly supported under the rubric of quality assurance (Fig. 3).9- 12 There are three phrases intermingled regarding quality: quality assurance,13 quality assessment,14 and quality management. 1S Quality assessment determines the level of current quality, for example, how well are we doing now? Quality assurance sets a standard against which care is measured: How well are we doing compared to the standard? Quality management represents the goal of continuous improvement in patient care-not "how are we doing?" but rather "can we do it any better?" Think of your own practice and ways in which you may have changed it for the better in the past
o
A
--C----_ B
--
--__
E
-- -F
.............. -
Time - +
or wish to change it now. In real life most problems are related to the structure, or the facilities we work in; the process, or the way we organize ourselves to do work; or fuzziness in setting goals: If you don't know where you're going, you'll never know if you get there. 15 Codman's revolutionary ideas were not quickly adopted by medicine but they were picked up by industry.9,10,16 Continuous improvement by quality management was refined by Deming and Juran and taken to Japan after World War II. There, quality management has become an integral part of the business culture and, not incidentally, a crucial part of the success of Toyota, Sony, and the like. Integral to the continuous improvement concept is the understanding that just as problems are commonly due to defects in structure, process, and goal definition, they are rarely due to problems of will, skill, or motivation. Codman, Deming, and Juran implicitly reject what Berwick15 has called the Theory of Bad Apples, in which the job of quality management is to identify and discard bad apples by a rigorous inspection process. For medical practitioners, this means quality by recertification, litigation, and minimum standards. At its epitome it represents a horde of bureaucrats supervising health care providers, who spend so much time on paperwork they have no time to actually treat anyone. But the Theory of Bad Apples deals with only a small part of the problem. In essence, removing bad apples takes care of only the lower end of the bellshaped curve-the average quality is little affected (Fig. 4). Furthermore, it induces a predictable response among the inspectees-kill the messenger, distort the data, or find a scapegoat. 10 In other words, do as much as possible to avoid being singled out and as little as possible to actually improve the situation. Isn't that exactly where we are today with government, insurance companies, and lawyers looming overhead waiting for us to misstep? There is a better way. A rising tide raises all boats, and improvements in the average quality level move the entire bell-shaped curve and provide a better overall product than that obtained by merely pitching out the bad apples (Fig. 5). The Japanese call it "kaizen" -the idea that defects are not bad apples but a kind of treasure, something to learn from, an opportunity for improvement. 15 By taking an active stance, professional organizations such as ASHT can
I
FIGURE 3.
Quality assurance: Points A through F represent hypothetical problem rates. Quality assessment merely notes the level of quality. Any of the points, A, B, C, 0, E, or F, could represent an observed quality assessment. Without a reference point, all would need to be considered acceptable. Quality assurance compares the level with a fixed standard such as the line A-O; any result below the line would be considered acceptable. Quality management aims for continuous improvement, represented b y the line C-F. Whereas a value of C might be acceptable at an initial timepoint, after a period of quality improvement an equivalent or even lower value such as E could well be considered no longer acceptable because of the improvement in the quality process that has occurred in the intervening time.
The Theory of Bad Apples deletes only a part of the distribution of potential outcomes (shaded area), and leaves the rest untouched.
FIGURE 4.
October-December 1991
157
/
/
/ /
/
/
/
/
/
/
/
;-'-/
FIGURE 5.
REFERENCES Quality improvement affects quality at all levels.
take the lead in eliminating inefficient and ineffective care, improving the average level of care and promoting integration of clinical activities for better efficiency. At the same time such efforts can satisfy the cost-effectiveness concerns of government and thirdparty payers. The path is one ASHT is already on. Develop sound measuring tools 17 - 19 -and the ASHT annual program regularly addresses this issue. Ideally, an assessment should include anatomic (e.g., two-point discrimination), functional (object recognition), and subjective (patient satisfaction, return to work) measures. Most of the tools are available and well described. Technical support and professional training can enhance use of proper evaluation methods. Again, this is an area in which ASHT excels. Centralized data collection, for analysis of large groups of patients for clinical outcome, is also essential, but is more difficult to achieve. It implies first that we all use the same measurements, and then that we use them consistently. More interpractitioner cooperation is needed in this area. By collecting such information, however, we can vastly improve our ability to study outcomes of therapeutic interactions. 20 - 22 Only in this way can scientific comparisons finally replace the anecdotal series that pepper our literature. From such an understanding of clinical outcomes can come outcome-derived practice guidelines, to encourage those practices that we know work. 20 ,22 This would be a great improvement on the practice guidelines we use now, which are based loosely on our experience (reflected imperfectly through memory) and the advice of others, often containing more theory or personal preference than true knowledge,1,6 Outcome-based guidelines would be determined by actual clinical results: support and improve what works; discard what doesn't work. Finally, we must continuously review data, outcomes, and guidelines so that this process speeds rather than retards therapeutic progress. Our national government, many insurance carriers, and some research institutions have already embarked on this journey towards quality management, but they lack the clinical skills and perspective to devise a scheme that satisfies our vocational goal of caring, effective patient service. For the sake of our patients, as our professional duty, we must take part. In Cadman's words, "insurers are slowly, and
158
very expensively, accumulating in their own files a spurious kind of information about surgical results which will prove quite unjust as to showing what our profession can accomplish."4 For hand therapists, for all medical specialists, the challenge of leadership and innovation is there. Accept it, and make the future your own.
JOURNAL OF HAND THERAPY
1. Brook RH: Practice gUidelines and practing medicine. Are they compatible? JAMA 262:3027-30, 1989. 2. Bunnell S (ed.): Hand Surgery in World War II. Washington, DC, U.S. Government, 1955. 3. Orner GE, Graham WP: Development of certification in hand surgery. J Hand Surg 14A:589-93, 1989. 4. Cod man EA: The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, 1934. 5. Eddy DM: Connecting value and costs. Whom do we ask, and what do we ask them? JAMA 264:1737-9, 1990. 6. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ: Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med 321:1306-11, 1989. 7. Bercher HK, Altschule MD: Medicine at Harvard. Hanover, New Hampshire, University Press of New England, 1977, pp. 322-4. 8. Codman EA: Report of the Committee on the Standardization of Hospitals. Surg. Gynecol Obstet 18:7-12, 1914. 9. Donabedian A: The end results of health care: Ernest Codman's contribution to quality assessment and beyond. Milbank Q 67(2):233-56, 1989. 10. Berwick DM: Improving quality in medical care. The ParkNicollet Bulletin 34(1):5-16, 1990. 11. Lanning JA: The health care quality quagmire: Some signposts. Hosp Health Serv Admin 35(1):39-54, 1990. 12. Reverby S: Stealing the golden eggs: Ernest Amory Codman and the science and management of medicine. Bull Hist Med 55:156-71, 1981. 13. Lohr KN, Schroeder SA: Special report: A strategy for quality assurance in Medicare. N Engl J Med 322:707-12, 1990. 14. Gartland JJ: The orthopaedic quality assessment effort. Jefferson Orthop J 18:61-6, 1989. 15. Berwick DM: Sounding board: Continuous improvement as an ideal in health care. N Engl J Med 320:53-6, 1989. 16. Laffel G, Blumethal D: The case for using industrial quality management science in health care organizations. JAMA 262:2869-73, 1989. 17. Dellon AL... Mackinnon SE: Selection of the appropriate parameter to measure neural regeneration. Ann Plast Surg 23(3):197-202, 1989. 18. Grunert BK, Wertsch JJ, Matloub HS, McCallum-Burke S: Reliability of sensory threshold measurement using a digital vibrogram. J Occup Med 32(2):100-2, 1990. 19. Horger MM: The reliability of goniometric measurements of active and passive wrist motions. Am J Occup Ther 44(4):3428, 1990. 20. Epstein AM: Sounding board: The outcomes movement- Will it get us where we want to go? N Engl J Med 323:266-70, 1990. 21. Leape LL, Park RE, Solomon DH, Chassin MR, Kosecoff J, Brook RH: Ones inappropriate use explain small-area variations in the use of health care services? JAMA 263:669-72, 1990. 22. Roper WL, Winkenwerder W, Hackbarth GM, Krakauer H: Special article: Effectiveness in health care. An initiative to evaluate and improve medical practice. N Engl J Med 319:1197202, 1988.
G~EST EDITORIAL J
Quality Improvement in Hand Therapy Peter C. Amadio, MD Associate Professor of Orthopaedic Surgery, M ayo Medical School; Consultant in Orthopaedics, M ayo Clinic, Rochester, Minnesota
and therapy, like hand surgery, began to
H organize as a defined area of special interest after World War II, primarily as a result of the hand centers that were established at military hospitals around the United States by Sterling Bunnell. 1,2 The young staff of those centers, taught by Bunnell, organized shortly after World War II to form the American Society for Surgery of the Hand . By the early 1970s, hand surgery was an acknowledged specialty.3 The American Society for Surgery of the Hand was widely recognized for its educational activities, and hand surgeons began efforts to form a board, or at least obtain board-level recognition in the form of a qualifying examination, for hand surgery, as a way of establishing minimum standards in hand surgery. 3 In 1989, the American Boards of Orthopedic Surgery and General Surgery offered the first certificate of added qualifications in hand surgery. In 1990, the American Board of Plastic Surgery also began to offer a certificate of added qualifications in hand surgery. In 1978 the American Society for Hand Therapists was formed and without delay began similar
Correspondence and reprint requests to Peter C. Amadio, MD, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905.
educational efforts. Hand therapists have moved with even greater speed in establishing a certifying examination. In May 1991, the Hand Therapy Certification Commission offered its first certifying examination in hand therapy. What is next? Is certification of minimum qualifications enotIgh? And if the provider must meet minimum standards, what about the services provided? Among the smorgasbord of health care offerings available, what services are of proven clinical benefit? How does the patient distinguish sham and hype from clinical truth? How will insurance companies decide to reimburse, for example, hand therapy services? All medical providers must deal with such issues. In the past, patients and insurers were considered by some medical providers to be a combination of golden goose and ostrich, creatures with their heads in the sand happily providing golden eggs, no questions asked, to the awaiting practitioner (Fig. 1).4 Those days are past. Instead, what we hear today are calls to justify what we do: practice guidelines, standards of care, clinical policies, and the like. L5,6 Whether we like it or not, we are being held accountable for our actions. We may choose to be observers and let others make the rules, but as professionals that is nota choice. With vocation comes October-December 1991
155
----~----
FIGURE 1. The Back Bay Golden Goose Ostrich, as seen by Codman. From: Codman fA: The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, 1934, p. XXVI.
responsibility. Furthermore, the drive and initiative of ASHT makes such a passive stance inconceivable. ASHT has been and should continue to be a leader in defining the place of hand therapy in clinical practice. These problems are by no means new. They were all reviewed nearly a century ago by a remarkably original thinker: the surgeon Ernest Amory Codman. Codman was born to wealth and privilege in the Boston high society of the late 19th century. He was rather eccentric, and managed to antagonize most of his contemporaries,? but he also accomplished a number of great things. He was among the first to correctly diagnose and treat appendicitis and duodenal ulcer. 4 He produced the first radiographic monograph on scaphoid fractures. 4 He was a founder of the American College of Surgeons. 4 He helped organize what is now the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).8 He helped organize a tumor registry, which was a forerunner of the American Cancer Society. 4 He wrote the first textbook on shoulder disorders.4 Lastly, and the topic of this paper, he fought vigorously all his life for what he called the End Result Idea. This idea so consumed him that one of his main purposes in writing his shoulder textbook was actually to gain wider circulation for his End Result concept (Fig. 2).4 This concept was explained in a 40-page autobiographical prologue (complete with a graphic display of his life, including even such details as the names and life spans of all his pet dogs) and a 30-page epilogue to the shoulder text. As if that were not enough, each book came with a four-page insert further expanding on the benefits of the End Result Idea. The End Result Idea is simple, yet profound. It has yet to be completely adopted by medicine in practice, although most accept it in theory. His End 156
JOURNAL OF HAND THERAPY
FIGURE 2. The fnd Result Idea banner, held aloft by the Shoulder balloon. From: Codman fA: The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa (epilogue). Boston, 1934, p. 29.
Result Idea is "merely the common sense notion that every hospital [substitute health care provider for 1990s relevance] should follow every patient it treats long enough to determine whether or not the treatment has been successful and then to inquire "if not, why not," with a view of preventing a similar failure in the future."4 All the hallmarks of modern quality improvement measures are there. 9 1t is inclusive (every
patient) and comprehensive (long enough) and it calls for defined goals and outcomes (whether or not treatment has been successful) with analysis and feedback (if not, why not). In individual practitioner terms we can ask "Why is our quality ever suboptimal? Why is time wasted? Why does work need to be done over? Why is data lost or not collected? Is it our skill, judgment, knowledge, equipment, or facilities? Is it something to do with our patients' diseases or the social conditions in which they live? Are other causes involved? Of course many of these issues are addressed individually in clinical research, but it is their integration, in the End Result Idea, that leads most readily to improvements in the care we provide. I'ndeed, Codman's Committee on Hospital Standardization8 (now the JCAHO) and his tumor registry were designed by him specifically to put in action the End Result Idea. He and the other founders of the American College of Surgeons considered the End Result "tail" more important than the College "dog," and felt the creation of the latter was needed to promote the former. 4 Nowadays the End Result Idea is mostly supported under the rubric of quality assurance (Fig. 3).9- 12 There are three phrases intermingled regarding quality: quality assurance,13 quality assessment,14 and quality management. 1S Quality assessment determines the level of current quality, for example, how well are we doing now? Quality assurance sets a standard against which care is measured: How well are we doing compared to the standard? Quality management represents the goal of continuous improvement in patient care-not "how are we doing?" but rather "can we do it any better?" Think of your own practice and ways in which you may have changed it for the better in the past
o
A
--C----_ B
--
--__
E
-- -F
.............. -
Time - +
or wish to change it now. In real life most problems are related to the structure, or the facilities we work in; the process, or the way we organize ourselves to do work; or fuzziness in setting goals: If you don't know where you're going, you'll never know if you get there. 15 Codman's revolutionary ideas were not quickly adopted by medicine but they were picked up by industry.9,10,16 Continuous improvement by quality management was refined by Deming and Juran and taken to Japan after World War II. There, quality management has become an integral part of the business culture and, not incidentally, a crucial part of the success of Toyota, Sony, and the like. Integral to the continuous improvement concept is the understanding that just as problems are commonly due to defects in structure, process, and goal definition, they are rarely due to problems of will, skill, or motivation. Codman, Deming, and Juran implicitly reject what Berwick15 has called the Theory of Bad Apples, in which the job of quality management is to identify and discard bad apples by a rigorous inspection process. For medical practitioners, this means quality by recertification, litigation, and minimum standards. At its epitome it represents a horde of bureaucrats supervising health care providers, who spend so much time on paperwork they have no time to actually treat anyone. But the Theory of Bad Apples deals with only a small part of the problem. In essence, removing bad apples takes care of only the lower end of the bellshaped curve-the average quality is little affected (Fig. 4). Furthermore, it induces a predictable response among the inspectees-kill the messenger, distort the data, or find a scapegoat. 10 In other words, do as much as possible to avoid being singled out and as little as possible to actually improve the situation. Isn't that exactly where we are today with government, insurance companies, and lawyers looming overhead waiting for us to misstep? There is a better way. A rising tide raises all boats, and improvements in the average quality level move the entire bell-shaped curve and provide a better overall product than that obtained by merely pitching out the bad apples (Fig. 5). The Japanese call it "kaizen" -the idea that defects are not bad apples but a kind of treasure, something to learn from, an opportunity for improvement. 15 By taking an active stance, professional organizations such as ASHT can
I
FIGURE 3.
Quality assurance: Points A through F represent hypothetical problem rates. Quality assessment merely notes the level of quality. Any of the points, A, B, C, 0, E, or F, could represent an observed quality assessment. Without a reference point, all would need to be considered acceptable. Quality assurance compares the level with a fixed standard such as the line A-O; any result below the line would be considered acceptable. Quality management aims for continuous improvement, represented b y the line C-F. Whereas a value of C might be acceptable at an initial timepoint, after a period of quality improvement an equivalent or even lower value such as E could well be considered no longer acceptable because of the improvement in the quality process that has occurred in the intervening time.
The Theory of Bad Apples deletes only a part of the distribution of potential outcomes (shaded area), and leaves the rest untouched.
FIGURE 4.
October-December 1991
157
/
/
/ /
/
/
/
/
/
/
/
;-'-/
FIGURE 5.
REFERENCES Quality improvement affects quality at all levels.
take the lead in eliminating inefficient and ineffective care, improving the average level of care and promoting integration of clinical activities for better efficiency. At the same time such efforts can satisfy the cost-effectiveness concerns of government and thirdparty payers. The path is one ASHT is already on. Develop sound measuring tools 17 - 19 -and the ASHT annual program regularly addresses this issue. Ideally, an assessment should include anatomic (e.g., two-point discrimination), functional (object recognition), and subjective (patient satisfaction, return to work) measures. Most of the tools are available and well described. Technical support and professional training can enhance use of proper evaluation methods. Again, this is an area in which ASHT excels. Centralized data collection, for analysis of large groups of patients for clinical outcome, is also essential, but is more difficult to achieve. It implies first that we all use the same measurements, and then that we use them consistently. More interpractitioner cooperation is needed in this area. By collecting such information, however, we can vastly improve our ability to study outcomes of therapeutic interactions. 20 - 22 Only in this way can scientific comparisons finally replace the anecdotal series that pepper our literature. From such an understanding of clinical outcomes can come outcome-derived practice guidelines, to encourage those practices that we know work. 20 ,22 This would be a great improvement on the practice guidelines we use now, which are based loosely on our experience (reflected imperfectly through memory) and the advice of others, often containing more theory or personal preference than true knowledge,1,6 Outcome-based guidelines would be determined by actual clinical results: support and improve what works; discard what doesn't work. Finally, we must continuously review data, outcomes, and guidelines so that this process speeds rather than retards therapeutic progress. Our national government, many insurance carriers, and some research institutions have already embarked on this journey towards quality management, but they lack the clinical skills and perspective to devise a scheme that satisfies our vocational goal of caring, effective patient service. For the sake of our patients, as our professional duty, we must take part. In Cadman's words, "insurers are slowly, and
158
very expensively, accumulating in their own files a spurious kind of information about surgical results which will prove quite unjust as to showing what our profession can accomplish."4 For hand therapists, for all medical specialists, the challenge of leadership and innovation is there. Accept it, and make the future your own.
JOURNAL OF HAND THERAPY
1. Brook RH: Practice gUidelines and practing medicine. Are they compatible? JAMA 262:3027-30, 1989. 2. Bunnell S (ed.): Hand Surgery in World War II. Washington, DC, U.S. Government, 1955. 3. Orner GE, Graham WP: Development of certification in hand surgery. J Hand Surg 14A:589-93, 1989. 4. Cod man EA: The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, 1934. 5. Eddy DM: Connecting value and costs. Whom do we ask, and what do we ask them? JAMA 264:1737-9, 1990. 6. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ: Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med 321:1306-11, 1989. 7. Bercher HK, Altschule MD: Medicine at Harvard. Hanover, New Hampshire, University Press of New England, 1977, pp. 322-4. 8. Codman EA: Report of the Committee on the Standardization of Hospitals. Surg. Gynecol Obstet 18:7-12, 1914. 9. Donabedian A: The end results of health care: Ernest Codman's contribution to quality assessment and beyond. Milbank Q 67(2):233-56, 1989. 10. Berwick DM: Improving quality in medical care. The ParkNicollet Bulletin 34(1):5-16, 1990. 11. Lanning JA: The health care quality quagmire: Some signposts. Hosp Health Serv Admin 35(1):39-54, 1990. 12. Reverby S: Stealing the golden eggs: Ernest Amory Codman and the science and management of medicine. Bull Hist Med 55:156-71, 1981. 13. Lohr KN, Schroeder SA: Special report: A strategy for quality assurance in Medicare. N Engl J Med 322:707-12, 1990. 14. Gartland JJ: The orthopaedic quality assessment effort. Jefferson Orthop J 18:61-6, 1989. 15. Berwick DM: Sounding board: Continuous improvement as an ideal in health care. N Engl J Med 320:53-6, 1989. 16. Laffel G, Blumethal D: The case for using industrial quality management science in health care organizations. JAMA 262:2869-73, 1989. 17. Dellon AL... Mackinnon SE: Selection of the appropriate parameter to measure neural regeneration. Ann Plast Surg 23(3):197-202, 1989. 18. Grunert BK, Wertsch JJ, Matloub HS, McCallum-Burke S: Reliability of sensory threshold measurement using a digital vibrogram. J Occup Med 32(2):100-2, 1990. 19. Horger MM: The reliability of goniometric measurements of active and passive wrist motions. Am J Occup Ther 44(4):3428, 1990. 20. Epstein AM: Sounding board: The outcomes movement- Will it get us where we want to go? N Engl J Med 323:266-70, 1990. 21. Leape LL, Park RE, Solomon DH, Chassin MR, Kosecoff J, Brook RH: Ones inappropriate use explain small-area variations in the use of health care services? JAMA 263:669-72, 1990. 22. Roper WL, Winkenwerder W, Hackbarth GM, Krakauer H: Special article: Effectiveness in health care. An initiative to evaluate and improve medical practice. N Engl J Med 319:1197202, 1988.