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APPLYING SHEWHART'S CONTROL CHARTS TO CLINICAL GOVERNANCE (p 463)

February 07, 2001

A theory of variation used for quality control in the manufacturing industry since the 1920s could have helped in the earlier detection of recent UK health crises, suggest authors of an article in this week's issue of THE LANCET.

The physicist and engineer Walter Shewhart devised a simple graphical method based on mathematical theory and practical concerns, called a control chart, to discriminate between two sources of variation; common-cause variation, and special-cause variation. A control chart has three lines: the central line is the mean (average), and the upper and lower lines are termed control limits. Control limits represent the limits of common-cause variation. A data point that falls outside these control limits (or unusual patterns on the control chart) suggest a special cause. The authors, from the University of Birmingham, UK, state that control charts could have identified special-cause variation in childhood mortality after cardiac surgery as early as 1987. No action was taken until 1998, when problems were identified at Bristol Royal Infirmary. Similarly, the authors argue that control charts could have identified a high number of deaths among elderly women in the area where the general practitioner Harold Shipman worked. This was beyond the common-cause limit in 1993 and from 1995-98.

Tom Marshall (one of the authors) comments: "The crux of the problem is to understand variation. In the UK health service, some variation in outcome is inevitable. Because such variation is common to the system as a whole, the solution is to improve the system as a whole. Some variation is caused by special circumstances affecting one hospital or centre. The solution is to investigate and deal with these circumstances".

He concludes: "Control charts guide action. This is their real advantage over approaches such as league tables. They tell us when there is a genuine difference - a difference we should investigate. Just as importantly, they tell us when the differences are likely to be due to chance - when there is no need to investigate. Control charts proved invaluable to improvement efforts in industry over the past 50 years. They could be invaluable in improving health care."

(Quotes by e-mail; they do not appear in the published paper).

Contact: Dr Tom Marshall, Department of Public Health & Epidemiology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK; T) +44 (0)121 414 7422; F) +44 (0)121 414 7878; E) t.p.marshall@bham.ac.uk

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