Bristol, Shipman, and clinical governance: Shewhart's forgotten lessons

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Abstract

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.

Details

Original languageEnglish
Pages (from-to)463-467
Number of pages5
JournalLancet
Volume357
Issue number9254
Publication statusPublished - 10 Feb 2001