Applying Total QualityManagement Conceptsto Public Health Organizations

ARNOLD D. KALUZNY, PhDCURTIS P. McLAUGHLIN, DBAKIT SIMPSON, DrPH

The authors are with the University of North Carolina at

Chapel Hill. Dr. Kaluzny is Professor and Dr. Simpson isAssistant Professor of Health Policy and Administration at theSchool of Public Health. Dr. McLaughlin is Professor of HealthPolicy and Administration, School of Public Health, andProfessor of Business Administration, School of Business. Theyare Senior Associates of the University's Cecil G. Sheps Centerfor Health Services Research.

Tearsheet requests to Arnold D. Kaluzny, PhD; UNC, ShepsCenter, Chase Hall, Chapel Hill, NC 27701-7490; tel. (919)966-5011.

Synopsis.......

Total quality management (TQM) is a participa-tive, systematic approach to planning and imple-menting a continuous organizational improvementprocess. Its approach is focused on satisfyingcustomers' expectations, identifying problems,building commitment, andpromoting open decision-

making among workers. TQM applies analyticaltools, such as flow and statistical charts and checksheets, to gather data about activities within anorganization. TQM uses process techniques, suchas nominal groups, brainstorming, and consensusforming to facilitate communication and decisionmaking.

TQM applications in the public sector and partic-ularly in public health agencies have been limited.The process of integrating TQM into public healthagencies complements and enhances the ModelStandards Program and assessment methodologies,such as the Assessment Protocol for Excellence inPublic Health (APEX-PH), which are mechanismsfor establishing strategic directions for publichealth.

The authors examine the potential for usingTQM as a method to achieve and exceed standardsquickly and efficiently. They discuss the relation-ship of performance standards and assessmentmethodologies with TQM and provide guidelinesfor achieving the full potential of TQM in publichealth organizations. The guidelines include rede-fining the role of management, defining a commoncorporate culture, refining the role of citizen over-sight functions, and setting realistic estimates of thetime needed to complete a task or project.

TOTAL QUALITY MANAGEMENT (TQM) is a partici-pative, systematic approach to planning and imple-menting a continuous organizational improvementprocess.

Its approach is focused on satisfying customers'expectations, identifying problems, building com-mitment, and promoting open decision-makingamong workers. TQM applies analytical tools, suchas flow and statistical charts and check sheets, togather data about activities within an organization.TQM uses process techniques, such as nominalgroups, brainstorming, and consensus forming tofacilitate communication and decision making.TQM has arrived on the health services scene, or

at least in parts of the health services system. TheJoint Commission on the Accreditation of Health-care Organizations, for example, has incorporatedTQM concepts in its Agenda for Change. TheAmerican Hospital Association, through its Hospi-tal Research and Educational Trust, has published

a report to help hospitals design and implementTQM (1). Consulting organizations have developedprograms to educate health services managers,physicians, and other health personnel on TQM.Hospitals and HMOs increasingly are implementingit (2). Some will succeed in problem solving andplanning using TQM, but others may fail (3, 4).The increasing use of TQM is an exciting devel-

opment, but TQM application lags in the processof providing health services in the public sector,specifically public health agencies. TQM offerspublic health organizations a unique opportunity toadopt a powerful tool for strengthening manage-ment and presents a fundamental challenge topublic health administrators. We describe the po-tential of TQM as a major managerial innovation,compared with the current management of manypublic health agencies and offer guidelines to helpusers realize its full potential in public healthapplications.

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Standards and Assessment

Standards in the practice of public health tradi-tionally emphasized (a) health outcomes, (b) flexi-bility to allow communities to establish and quan-tify their own objectives, and (c) the role ofgovernment as a residual guarantor that is responsi-ble for assuring that prevention services are pro-vided through community agencies, concepts thatare reflected in the Model Standards published in1985 (5). The edition of Model Standards publishedby the American Public Health Association in 1991(6) links standards to meeting the health goals forthe nation in the year 2000 (7). The standards andthe year 2000 objectives are an important strategicplanning component, providing public health agen-cies with (a) a synthesis of current scientific knowl-edge of health promotion and disease prevention,(b) statistical data on the current state of thenation's health, and (c) a prioritized list of specifichealth objectives.The recent development and availability of the

Assessment Protocol for Excellence in PublicHealth (APEX-PH) provides a methodology forsystematically assessing departmental operationsrelative to meeting standards. APEX-PH providesagency leaders a clear, comprehensive, and flexibleprotocol for assessing organizational and commu-nity resources and needs. The workbook formathelps agency leaders to meet national health pro-motion and disease prevention objectives (7) at thecommunity level. The APEX-PH protocol is acollaborative effort of the American Public HealthAssociation, the Association of Schools of PublicHealth, the Association of State and TerritorialHealth Officers, the Centers for Disease Control,the National Association of County Health Offi-cials and the U.S. Conference of Local HealthOfficers (8).The availability of Model Standards and APEX-

PH provides health agencies with a rational methodto assess their potentials and goals for healthoutcomes. Guided by community health objectivesand assessment findings, managers can formulatean agency-community health plan that can serve to

direct work within programmatic areas. The healthobjectives that define the direction of an agency'sstrategy need to be broad and multi-dimensional.The organizational assessment process provides a

framework for developing and maintaining thecapacity to carry out a community health plan. Toassure that program objectives are met, healthdepartments traditionally have depended on a sys-tem of performance standards and quality assur-ance methods. While these efforts are necessary,they are not sufficient to meet the challenges nowfacing public health agencies. Instead of relying ontraditional performance standards and quality as-surance methods, TQM offers a means to improveon-going processes and to enhance agency perfor-mance within a changing environment.

TQM Strengths

TQM focuses on work processes, applying ana-lytical and behavioral techniques to improve thoseprocesses within an organization. For example, agroup of nursing and laboratory personnel mayselect a process for improvement, such as untimelydeliveries of laboratory test results to a prenatalclinic. Using a series of flow diagrams, they may beable to identify the steps involved in the processand the factors that may be contributing to delays.Based on this understanding, the group may beable to identify and try steps to improve thetimeliness of the test results, monitoring the resultsto try to achieve continuous improvement.

In such an application, TQM presents a funda-mental challenge to the use of internal performancestandards to achieve public health objectives (9,10). While the use of performance standards can bea starting point for TQM, continuous quality man-agement goes beyond conforming to managementstandards. TQM includes systematic analysis of thework performed by the organization, with emphasison the horizontal integration of services across pro-gram areas. Attention can be given, for example,to identifying and reducing variations in the workperformance of inter-disciplinary teams or naturalwork groups. Improvement is based on both out-come and process. An organization must constantlyimprove its problem-solving capacity, using perfor-mance standards as leverage in the improvementprocess. As described by some advocates, such or-ganizations ". . . continuously push at the marginsof their expertise, trying on every front to be a bitbetter than before. Standards to them are ephem-eral milestones on the road to perfection. . ..."(11).

2W PubIc H"uh Reports

TQM requires that change be based on the needsand desires of patients, clients, and health person-nel involved in the entire work process, and possi-bly across programmatic areas. TQM requiresmeaningful participation on all personnel levels. Inparticular, TQM requires rapid and thoughtfulresponse by top management to suggestions madeby participating personnel. TQM is the essence ofthe structured, participative philosophy of the rec-ommendations for using the Model Standards andAPEX-PH process to achieve community healthobjectives.TQM requires that all personnel have a clear

understanding of the work process and its relation-ship to the larger system. TQM requires using arigorous process analysis and evaluation of allongoing activities and the recognition and applica-tion of underlying psycho-social principles affectingpeople and groups within the organization. TQMrequires accepting the fundamental assumption thatmost problems encountered in public health agen-cies are not the result of errors by individualpersons, but of the inabilities of the system, withinwhich all personnel must function, to performadequately.Whereas Model Standards and APEX-PH focus

on strategic health outcome objectives and commu-nity stakeholders as the ultimate health departmentcustomers, TQM examines each link in the processused to achieve the public health goals. The cus-tomer in TQM is not only the community or clientfor whom services are designed, but the many usersof the agency's output, including health providerswithin the organization itself. The criterion is notwhether or not the work meets some managementperformance standard per se, but whether the user(often a member of a different profession, or a setof personnel with the agency, or a host of otherpublic and private health service agencies) is satis-fied with the timeliness and usefulness of theservice being provided by or within the publichealth agency. The managerial challenge is not toassure adherence to fixed standards (12), but tospend time and energy in facilitating and assuringcontinual improvement in the many interrelatedprocesses that are the work of the department.

Traditional Performance Standards and TQM

To illustrate the potential of TQM in publichealth, the following table contrasts TQM withtraditional management approaches that use perfor-mance standards. The two views are not intendedto be mutually exclusive, but to provide a heuristic

for understanding the fundamental similarities anddifferences.

Traditional modelLegal or professional author-

itySpecialized accountabilityAdministrative authorityMeeting standards

Longer planning horizonQuality assurance

TQM modelCollective or managerial

responsibilityProcess accountabilityParticipationMeeting process and perfor-mance expectations

Shorter planning horizonContinuous improvement

Legal and professional authority versus collectiveand managerial responsibility. A typical publichealth department represents an amalgam of legaland professional authority. Activities such as sani-tation in restaurants, assurance of safe water sup-plies, and control of epidemics are driven by legalauthority. Other activities, such as family planningand prenatal care, are medical services made avail-able, and these processes are characterized byprofessional autonomy and control. Both legal andprofessional control processes combine to assurethe enforcement of employee performance stan-dards and are perfect candidates for improvement.For example, the process of sanitation inspectionmay be filled with variation and unnecessary cost,and to the extent that the process is truly under-stood, provides an opportunity for improving effi-ciency and customer satisfaction.The TQM model focuses on the system, empha-

sizing collective managerial responsibility, not sim-ply legal or professional mandates. TQM assumesthat the system is the primary source of problems,and by better understanding that system, providesopportunities for improving service. TQM focuseson the work process, not on the individual worker.The objective is not to rely solely on legal orprofessional authority, but to challenge the inter-disciplinary work group involved with the processto assume ownership of that process and takeresponsibility for its continuous improvement. Thegroup most expert at improving this process is onethat includes the workers currently involved in theprocess. In this respect, the process is conceptuallycompatible with providing public health servicesthrough a multidisciplinary team process.

Specialized accountability versus process account-ability. Public health professionals traditionallyexpect autonomy in performing their work. As longas there is a reasonable approximation to thestandard, their autonomy is often assured. Unfor-tunately, intense needs for specialization, combined

May-June 1992, Vol. 107, No. 3 259

with professional autonomy, segment the workprocess. Professional groups, reinforced by specificstandards, assume ownership of only part of thework process, and no single group is held account-able for the total process.Under the performance standards approach, indi-

vidual professionals seek to optimize their portionof the process often with limited knowledge of thesystem within which their portion of the processworks. If individual providers own parts of theprocess, they can improve only parts of thatprocess. For example, nurses may try to reduce thewaiting time for mothers and babies in the well-baby clinic. But, since they are involved with onlypart of the process, albeit a significant component,any unilateral change may create problems andresistance among clerical personnel, laboratorytechnicians, those involved with the Special Supple-mental Food Program for Women, Infants, andChildren (WIC), and perhaps others, who have notbeen involved in their effort to reduce waiting time.TQM requires that improvement be the responsi-

bility of all those involved in the process. ThusTQM challenges professional autonomy and de-mands accountability for the total work process.Accountability for the total process requires thatchange in the process be the responsibility of allpersonnel, thus emphasizing process improvementrather than specialized accountability.

Administrative authority versus participation.Under a system of performance standards, opera-tional standards are likely to be set by someexternal credentialing body and implemented byadministrative authority. TQM instead emphasizesinterdisciplinary teams working toward the objec-tives set by the customer, who may be public healthprofessionals, payers, or clients or family members.By using interdisciplinary teams or groups, TQMmakes workers and their front-line supervisorsresponsible for quality, not an administratorcharged with monitoring standards.

Maintaining quality no longer consists of simplytaking names and penalizing those who make errorsor deviate from the standard. It means settingperformance expectations that are realistic in thelocal setting, helping personnel to monitor theirown performance, and empowering them to takecorrective action. For example, funding regulationsmay require that a clinic be held twice a week for 4hours, while patient preference might be that theclinic be held twice a week for 3 hours each timeand be open on Saturday mornings for the 2remaining hours. Thus the obvious challenge is to

make the health department respond and becomecustomer-driven and not merely a rule-driven organ-ization.

Meeting standards versus process and perfor-mance expectations. The performance standardsapproach is applicable to a wide range of serviceareas. If one meets the standard, then one candivert energies and resources to meeting anotherstandard. Standards are anonymous, potentiallycompelling, and often provide powerful leveragefor financing. Standards often are augmented bythe larger profession, by other agencies, and by thecourts. Meeting a new standard may require newresources. Since these standards are externally im-posed, they transfer the onus of requesting moreresources to nonagency personnel.That is not the case with TQM. TQM requires

that the agency tak-e responsibility for its ownstandards and for their implementation. Anonymityis removed. The agency has to be explicit about itscurrent record of performance and commit itself tocontinuous improvement. For example, State rulesmay require that two attempts be made to contacta patient whose Papanicolaou (Pap) smear resultcomes back positive. Agency personnel may decideto improve the notification process and use statis-tics and process analysis to challenge personnel toincrease the rate of successful notification. Theimprovement process is, in this case, not guided bythe external imposition of standards, but by thedynamic process of group effort.Benchmarking involves comparing current activi-

ties and outcomes against the best of. the competi-tion, the idea being to develop a product or processthat is better than that of the competition. Theissue is not how well the agency performs a servicecompared with relevant organizations, but how theservice is provided within other standards, com-pared with a given agency. While competition maynot be the operative term for public health depart-ments, since they have a monopoly on many of theirservices, public health agencies do have peer orga-nizations upon which to base their comparisons.The reliance on peers f2r the standard means

that the standard change as soon as one peerachieves a higher level of performance. One of themanagement lessons learned from the Japanese isthat different and higher expectations can lead tobetter results. Benchmarks do not necessarily haveto come from close peers. Indeed, the goal forreducing clinic waiting times can be a local bank ora popular restaurant, rather than a neighboringclinic. This changes staff perspective from one of

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"we are no worse than anyone else," to one of"how good can we become?"

Long planning horizon versus short planninghorizon. TQM may help bridge the gap betweenstrategy and performance. Model standards providefor long-term rather than short-term planning. Forexample, while the Model Standards Program (6)and APEX-PH emphasize flexibility and localapplicability, the process of development requiresextensive consultation with external groups. Thismakes it difficult to relate the standards to theday-to-day concerns of the operating agency.TQM, however, is an internally oriented, from-the-bottom-up approach meant to take effect over ashort period. The approach requires rapid feedbackto the group making recommendations in order tosupport and sustain their motivation. As improve-ments are made, staff members initiate the searchfor new sources of improvement as part of thecontinuous improvement process.

Quality assurance versus continuous improve-ment. Within the world of standards, quality assur-ance (QA) is the vehicle for retrospectively observ-ing deviations from a standard. QA measures havethe quality of measurability and place responsibilityon persons. Either standards are met or they arenot met. It is easy for providers, advocates, politi-cians, and courts to focus on deviations and notthe standard. Improvement of the standard hasgreat value. Improvement beyond the standard haslittle value and consequently little attention is paidto tradeoffs among standards.TQM takes a different approach to quality. It

requires focusing on the system as a source oferror, and emphasizes continuous improvement inperforming an activity. TQM emphasizes the factthat improving the system is part of the jobdescription of all personnel, not just managementor designated QA personnel.

Preparing for Change

The ultimate success of TQM in public healthdepends on the ability of public health officers,administrative managers, professionals, and over-sight groups to integrate the two approaches ofcommunity defined standards for health outcomesand TQM for process improvement to achievedesired outcomes. Success will depend on theirability to meet the following challenges.

Action 1: Redefine the role of management. The

achievement of community health outcomesthrough TQM requires that managers function bothvertically and horizontally within the organization.Horizontally, focus must be given to the work pro-cess that involves agency teams across, rather thansimply within, programmatic areas. Entry level cre-dentials and technical knowledge will be necessaryfor managers, but will not be sufficient. Manage-ment must become responsible for the work processthat transcends programmatic areas. That requiresa common sense of mission and vision for the fu-ture, as well as skills in epidemiology, effecting or-ganizational change, and using process analysis.Management, particularly top management, mustassume direct responsibility and participate in train-ing and skill-building activities.

Managerial change is required in the verticalrelationships within an organization. Top levelmanagers will do less decision making, yet will beresponsible for managing the development of asupportive environment and facilitating the changesrequired for reallocating resources needed in theprocess. Middle management will have responsibil-ity for monitoring the process and authorizing theprocess changes that are recommended by theinterdisciplinary improvement teams. First-linemanagement will assume more decision-making au-thority. This authority will be used in a consensual,rather than a directive, process.

Action 2: Define a supportive corporate culture.Within health care, there is a tendency to look forthe big breakthrough, the quick fix, and the goldstandard. While TQM occasionally produces abreakthrough, its philosophy is one of incessantchange, of working with what is available, but withvery high expectations. Imai (13), for example, ob-serves that Westerners focus on performance, whileEasterners are concerned with both process andperformance. Kilmann (14) further suggests thatchange will require pervasive modifications instructure, reward systems, inservice educationalphilosophy, management skills, and team buildingstrategies.

Specifically, a health department requires a cul-ture that supports continuous improvement in allthe processes by which it implements its programsand interacts with its clients, including never-endingimprovement in standards and their uses and val-ues. This means that the workers and managersknow and accept their starting point and focus onhow to improve to achieve a short run goal,followed by another, and so on. This means thatthey are willing to be evaluated on the rate of

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improvement, rather than on whether or not im-provement merely reached a specific level within astandard and maintained it. Clearly, the culturewill have to support the flexibility and creativityrequired to achieve the ends in time.

Action 3: Redefining the role of citizen oversightand regulation. Public health organizations aregoverned by citizen oversight groups and their mis-sion, goals, and objectives are strongly influencedby regulatory requirements. It is important that cit-izen oversight groups and regulatory agencies bebrought into the continuous improvement process.Oversight groups and regulatory agencies will haveto be convinced of the value of the process inwhich one measures the current level of perfor-mance and allocates the resources needed to reachan improved level in a continuous quest for qual-ity. They must provide the department with greaterbudgetary flexibility than previously, especially if arigid line item budget has been used. Interdiscipli-nary quality improvement teams quickly lose inter-est if improvement ideas are generated, but not im-plemented because of rigid line item budgetadherence.The purpose, process, and outcomes of regula-

tion must be re-examined to assess their influenceon health departments involved with TQM. Legisla-tors, relevant public officials, citizen oversightgroups, and public health managers must workclosely and support experimentation, in the form ofcarefully and continuously evaluated demonstrationprojects. Moreover, alliances involving industryand other health care providers already using TQMneed to be developed. Such alliances must influencerelevant legislative and regulatory bodies to supportenabling activities.

Action 4: Map a trajectory of objectives. Imple-menting TQM requires a trajectory of changes thatare expected over a period. It is not acceptable torequest additional resources under the threat thatfailure to provide resources will reduce compliancewith standard X and lose Y dollars. In fact, this

approach is debilitating in the long run. It ques-tions whether management has the initiative to setrelevant objectives and take into account theunique problems faced by the organization, beyondsimply complying with externally imposed stan-dards. Instead, TQM requires a series of objectivesthat facilitates discussion about tradeoffs in timeand in resources, and focuses attention on reducingcosts by improving the overall work process.

Action 5: Drive the benchmarking process fromthe top. The greatest challenge will be the bench-marking process. Professionals often consider theorganization at which they trained as the gold stan-dard, and are content to emulate that approach.They do not consider daily activities in processterms and are reluctant to collect and analyze pro-cess data. They hesitate to learn from what otherpeople are doing in very different settings. Topmanagement must provide leadership in pointingout that, while there are differences, much can belearned from the similarities. For example, it maybe difficult for public health professionals to con-sider emulating the way that Disneyland handleswaiting lines without feeling that their profession isbeing demeaned, but good examples of how othertypes of clinics handle waiting lines are available asa comparison. Private clinics, local hospitals, andother human service organizations can be used asbenchmarks.

Action 6: Create organizational slack. The effec-tive implementation of TQM can be seriously ham-pered if there are absolutely no resources to sup-port the improvement process. While processimprovement creates discretionary resources by re-ducing waste built into current work processes, ini-tially resources may be required if the improvementprocess is to be credible at the onset. Since man-agement does not know a priori the recommenda-tion, the resources cannot all be budgeted and re-serve resources must be available to speedimplementation. Failure to provide such resourcesonly guarantees failure. Assuring some slack re-sources, or at least resource flexibility, may be thegreatest challenge to the implementation of TQMin a public health agency.

Action 7: Empower the staff to address problems.Many public health professionals have learned notto venture beyond their own programmatic areas.They are content to either ignore problems or as-sume that problems are the responsibility of otherswithin the organization. TQM requires that profes-

262 Public Health Reports

sionals assume direct responsibility for identifica-tion and resolution of problems. This involves doc-umenting processes of work, including suchfundamental questions as what are the processes,what are their objectives, and how do they reallywork? Moreover, it requires an understanding ofhow the work of one group relates to and affectsthe work of another and the use of this knowledgeto gather and analyze data and make recommenda-tions to improve the work process. People need toovercome status barriers. Management must pro-vide rapid feedback on resulting proposals to im-prove operations. While each of these actions re-quires maturity in those meeting the challenge, theyalso require that processes be redesigned and that alearning environment be developed that is condu-cive to building customer and process knowledgethrough statistical and scientific thinking. Fortu-nately, both the importance of scientific thinkingand the use of statistics are accepted parts of pro-fessional public health practice. The challenge willbe to take these tools and apply them to internalwork processes and outcomes in the health depart-ment, instead of using them exclusively for prob-lem identification and process adjustment with re-gard to the larger community.

Action 8: Avoid the best practice syndrome. Whilethe use of TQM within public health requiresbenchmarking, it is important that public healthprofessionals avoid adopting so-called best practicethinking. Best practice cannot exist independentlyof the needs of the clients and the resources of theorganization. For example, in industry, competingfirms often achieve successful outcomes using strik-ingly different approaches. One involves comput-ers, while another does not. One relies heavily onrobots, while another does not. What is commonto all is that they develop innovative ways to meetthe demands that their customers place on them,given the resources that they have available. Fol-lowing best practice without respect to the strategicdemands of the organization's environment meansthat the organizations get the so-called flavor ofthe month in terms of new concepts that guidemanagement's search for solutions. Managementtechniques should never be panaceas to be appliedindiscriminately. The challenge is to broaden thearray of alternative approaches that managers canselect from, not to select one approach to be usedby everyone for everything.

Action 9: Set realistic time expectations. The suc-cessful integration of TQM, Model Standards, and

APEX-PH requires a realistic estimate of the timerequired to implement TQM and to observe its ef-fect. The process of adapting and institutionalizingTQM, even in a small health department, will re-quire a number of years. What is not known iswhether it is best to view the organization as an en-tity or to start with selected work processes amena-ble to change within parts of the organization.That course takes fewer resources initially and, if itis a success, will influence the attitudes of others.However, attitudinal changes at the top are so criti-cal that the failure to use TQM throughout the or-ganization can severely limit more restricted ef-forts.Even when TQM is supposedly implemented,

management must continually monitor its use toassure that it is fully institutionalized throughoutthe organization. For example, while Xerox Corpo-ration won the 1989 Malcolm Baldridge Award forits quality program, new issues concerning imple-mentation continued to surface 5 years after theprogram was initiated. Monitoring revealed thatemployee evaluation systems did not reflect com-mitment to TQM, and training in TQM was notincluded as employment criteria for entry levelmanagers.

Action 10: Make management a model for contin-uous improvement. Since people are more im-pressed with actions than words, managementneeds to model the process for the organization.Professionals especially will be looking for discrep-ancies between what is advocated and what is prac-ticed. Top management must provide the leadershipand must consciously use the process as part of theoverall operation. TQM is not a program to be im-plemented, but a process to be initiated.

Conclusions

Public health organizations and public healthpractice face continual challenges that require anew look at how and why we organize and manageservices (15). TQM, along with Model Standardsand the APEX-PH protocol, represent complemen-tary methods for assuring that excellent services areprovided to the community. As more health serviceorganizations within the private sector adopt TQMconcepts, the public health community needs toexamine the potential of TQM within its ownorganizational framework.TQM, combined with Model Standards and the

use of the APEX-PH protocol, provides an oppor-tunity for public health professionals to transform

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public health practice to meet the increasinglydifficult challenges we face.

References..................................

1. James, B. L.: Quality management for healthcare delivery.American Hospital Association, Hospital Research andEducational Trust, Chicago, IL, 1989.

2. Berwick, D., Godfrey, A., and Roessner, J.: Curing healthcare: new strategies for quality improvement. Jossey-BassPublishers, San Francisco, CA, 1990.

3. Berwick, D.: Continuous improvement as an ideal inhealthcare. N Engl J Med 320: 53-56, Jan. 5, 1989.

4. McLaughlin, C. P., and Kaluzny, A.: Total quality man-agement in health: making it work. Health Care ManageRev 15: 7-14, summer 1990.

5. American Public Health Association, Association of Stateand Territorial Health Officials, National Association ofCounty Health Officials, U.S. Conference of Local HealthOfficers, and Centers for Disease Control: Model stan-dards: a guide for community preventive health services.American Public Health Association, Washington, DC,1985.

6. American Public Health Association, Association of Stateand Territorial Health Officials, National Association ofCounty Health Officials, U.S. Conference of Local HealthOfficers, and Centers for Disease Control: Healthy com-munities 2000: model standards, guidelines for communityattainment of year 2000 national health objectives. Ed. 3.American Public Health Association, Washington, DC,1991.

7. Public Health Service, Office of the Assistant Secretary forHealth: Healthy people 2000: national health promotionand disease prevention objectives. DHHS Publication No.(PHS) 91-50212. Office of Disease Prevention and HealthPromotion. U.S. Government Printing Office, Washing-ton, DC, 1990.

8. American Public Health Association, Association ofSchools of Public Health, Association of State and Territo-rial Health Officials, Centers for Disease Control, NationalAssociation of County Health Officials, and U.S. Confer-ence of Local Health Officers: Assessment protocol forexcellence in public health (APEX-PH). American PublicHealth Association, Washington, DC, 1990.

9. Deming, S. E.: Out of the crises. Massachusetts Instituteof Technology, Center for Advanced Engineering Study,Cambridge, MA, 1986.

10. Juran, J. M.: Juran on planning for quality. The FreePress, New York, NY, 1988.

11. Hayes, R. H.: Wheelwright, S. C., and Clark, K. B.: Dy-namic manufacturing. The Free Press, New York, NY,1988.

12. Melcher, A., Acaf, W., Dun.ont, P., and Khouja, M.:Standard maintaining and continuous improvement sys-tems: experiences and comparisons. Interfaces 20: 24-40,May-June 1990.

13. Imai, M.: Kaizen: the key to Japan's competitive success.McGraw-Hill Publishing Co., New York, NY, 1986.

14. Kilmann, R.: Beyond the quick fix. Jossey-Bass Publish-ers, San Francisco, CA, 1989.

15. National Academy of Sciences, Institute of Medicine: Thefuture of public health. National Academy Press, Washing-ton, DC, 1988.

Blue Thursday? Homicideand Suicide Among Urban15-24-Year-Old BlackMale Americans

MICHAEL GREENBERG, PhDDONA SCHNEIDER, PhD, MPH

Dr. Greenberg is Professor, and Dr. Schneider is AssistantProfessor, Department of *Urban Studies and CommunityHealth, Rutgers University. Dr. Greenberg is also Co-Directorof the New Jersey Graduate Program in Public Health.

Tearsheet requests to Dr. Michael Greenberg, Department ofUrban Studies and Community Health, Rutgers University,Kilmer Campus, LSH B265, New Brunswick, NJ 08903, tele-phone 908-932-4006.

Synopsis................................

A comparative analysis was made of day of theweek variations in homicide and suicide deaths

among 15-24-year-old white males, black males,white females, and black females in the 22 countieswith the most black persons in the United States.Thirty-seven percent of black Americans and 14percent of white Americans lived in these denselypopulated counties.

The authors expected a weekend excess of homi-cide and a Monday excess of suicide. They found apronounced excess of homicides on weekends, espe-cially among white males. A slight excess of suicidewas observed on Monday, but other slight excessesof suicide were also found.

Young black males exhibited an unexpected ex-cess of homicides and suicides on Thursday. OnThursdays the black male-white male ratio forhomicide was 1.43 and for suicide, 1.26. Possibleexplanations for the young black males' blueThursday phenomenon are offered.

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