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Special Report

Medical Physics ­ 08/21/2007

The American Board of Radiology perspective on maintenance of certification: Part IV: Practice quality improvement in radiologic physics

G. Donald Frey, Geoffrey S. Ibbott, Richard L. Morin, Bhudatt R. Paliwal, Stephen R. Thomas , Jennifer Bosma The American Board of Radiology, 5441 East Williams Blvd, Tucson, AZ 85711 a) Author to whom correspondence should be addressed. Electronic mail: [email protected] Abstract Recent initiatives of the American Board of Medical Specialties (ABMS) in the area of maintenance of certification (MOC) have been reflective of the response of the medical community to address public concerns regarding quality of care, medical error reduction, and patient safety. In March 2000, the 24 member boards of the ABMS representing all medical subspecialties in the USA agreed to initiate specialty-specific maintenance of certification (MOC) programs. The American Board of Radiology (ABR) Maintenance of Certification program for diagnostic radiology, radiation oncology and radiologic physics has been developed, approved by the ABMS, and initiated with full implementation for all 3 disciplines beginning in 2007. The overriding objective of MOC is to improve the quality of health care through diplomate-initiated learning and quality improvement. The four component parts to the MOC process are: Part I: professional standing, Part II: evidence of life long learning and periodic self-assessment, Part III: cognitive expertise, and Part IV: evaluation of performance in practice (with the latter being the focus of this paper). The key components of Part IV require a physicist-based response to demonstrate commitment to practice quality improvement (PQI) and progress in continuing individual competence in practice. Diplomates of radiologic physics must select a project to be completed over the 10-year cycle that potentially can improve the quality of the diplomate's individual or systems practice and enhance quality of care. Five categories have been created from which an individual radiologic physics diplomate can select one required PQI project: 1) safety for patients, employees, and the public, 2) accuracy of analyses and calculations, 3) report turnaround time and communication issues, 4) practice guidelines and technical standards, and 5) surveys (including peer review of self-assessment reports). Each diplomate may select a project appropriate for an individual, participate in a project within a clinical department, participate in a peer review of a selfassessment report, or choose a qualified national project sponsored by a society. Once a project has been selected, the steps are: 1. collect baseline data relevant to the chosen project, 2. review and analyze the data, 3. create and implement an improvement plan, 4. re-measure and track, 5. report participation to the ABR, using the template provided by the ABR. These steps begin in Year 2, following training in Year 1. Specific examples of individual PQI projects for each of the three disciplines of radiologic physics are provided. Now, through the MOC programs, the relationship between the radiologic physicist and the ABR will be continuous through the diplomate's professional career. The ABR is committed to providing an effective infrastructure that will promote and assist the process of continuing professional development including enhancement of practice quality improvement for radiologic physicists.

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Key Words Maintenance of Certification, Practice Quality Improvement, ABR, ABMS

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Introduction and Position Statement Within the health care system of the United States, quality of care, medical error reduction, and 1-3 patient safety represent continuing themes that dominate public concern. Recent initiatives of the American Board of Medical Specialties (ABMS) in the area of maintenance of certification (MOC) 4-8 have been reflective of the response of the medical community to address these concerns. Advances in medical science and technology are moving forward at an unparalleled pace, and the rate of new information continues to accelerate. Outcomes and costs to diagnose and treat specific 9 diseases vary widely amongst physicians, hospitals, health care providers and regions of the country. To meet and address some of these challenges in the medical system, the ABMS, composed of 24 member boards representing all medical subspecialties in the USA, mandated in March 2000 that each board initiate specialty-specific MOC programs. Diplomates are no longer granted life-time certification, but need to have evidence of continuing medical education and knowledge, as well as a commitment to practice improvement. The American Board of Radiology (ABR) Maintenance of Certification program for diagnostic radiology, radiation oncology and radiologic physics has been developed, approved by the ABMS, and initiated with full implementation for all 3 disciplines beginning in 2007. The overriding objective of MOC is to improve the quality of health care through diplomateinitiated learning and quality improvement. It is a response to public expectation for competence of medical professionals. There are four component parts to the MOC process: Part I: professional standing, Part II: evidence of life long learning and periodic self-assessment, Part III: cognitive 10-12 expertise, and Part IV: evaluation of performance in practice. This paper addresses the ABR's Part IV component of MOC. The key components of Part IV require a physicist-based response to demonstrate commitment to practice quality improvement (PQI) and progress in continuing individual competence in practice. How do we measure competence when practices are diverse and roles are unique? The ABR's guidelines state that every diplomate of radiologic physics must select a project or projects that potentially can improve the quality of the diplomate's individual or systems practice and enhance quality of care. Key requirements for the ABR's Practice Quality Improvement (PQI) program (Part IV) are that each project be: (1) relevant to the diplomate's practice, (2) achievable in a practice setting, (3) designed to produce measurable results that are suitable for trending within a 10-year MOC cycle, and (4) able to effect quality improvement. We anticipate that most PQI projects will include the majority or all of the 6 general competencies defined for training and practice: practice knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and selfimprovement, and systems-based practice. A central element of PQI projects (Part IV) is to provide evidence of critical evaluation of the individual's performance in practice. The ultimate goal of each individual diplomate, as well as all diplomates collectively, must be to achieve ongoing improvement of practice (either individual or systems practice) and to demonstrate a commitment to maintaining competency as a radiologic physicist. Projects may be developed by the diplomates individually, by institutions or societies, or as a part of national registries. As long as the PQI project selected is meaningful, there is no penalty for the diplomate's failure to demonstrate improvement. At this juncture, only failure to participate and/or comply with ABR's reporting requirements for PQI will be considered unsatisfactory performance. 3

Radiologic Physics PQI Projects All Radiologic Physics diplomates must be trained in the process and procedures of quality improvement as they affect an individual's practice of radiologic physics. Training courses will be presented at national meetings and will be available in virtual libraries. Training in quality improvement is also available at many colleges, technical schools and on-line. In addition, there are many instructional books available. The diplomate should keep records of the training because a small fraction of people will be audited by the ABR. The individual program of PQI will require annual action and assessment over the 10-year MOC cycle (attestation within each individual's Personal Data Base (PDB) on the ABR website). Within year one of the initial 10-year cycle, diplomates must have documented training in the quality improvement process and techniques. Diplomates must initiate a PQI program in year 2. The diplomate will engage in one or more PQI projects over the 10-year cycle (Table 1). Progress in the PQI program as recorded in the diplomate's PDB will be reviewed annually by the ABR. A partial listing of documents that might prove useful as sources both for educational aspects of PQI and for selection of PQI projects is provided in Appendix I. In an effort to meet the diversity of radiologic physics practice, the ABR has created five categories from which an individual diplomate can select one required PQI project: 1) safety for patients, employees, and the public, 2) accuracy of analyses and calculations, 3) report turnaround time and communication issues, 4) practice guidelines and technical standards, and 5) surveys (including peer review of self-assessment reports). (Table 2.) The paragraphs that follow describe the rationale underlying each of these categories, suggest examples of PQI projects that might be undertaken by an individual diplomate, and offer suggestions as to how national or subspecialty societies could lend valuable aid to project development. Specific examples of individual PQI projects for each of the three disciplines of radiologic physics are provided on The ABR website (www.theabr.org/RP_MOC_PQI.htm). A potential secondary gain as data from PQI projects is compiled would be the production of national data repositories, allowing individual diplomates to compare their performance with that of their colleagues. Each radiologic physicist may select a project appropriate for an individual, participate in a project within a clinical department, participate in a peer review of a self-assessment report, or choose a qualified national project sponsored by a society. Once a project has been selected, the steps are: 1. collect baseline data relevant to the chosen project, 2. review and analyze the data, 3. create and implement an improvement plan, 4. re-measure and track, 5. report participation to the ABR, using the template provided by the ABR. These steps begin in Year 2, following training in Year 1 (Table 1). The reporting requirements are satisfied by electronic entry into a password-protected Personal Database (PDB) that has been set up for each diplomate by the ABR as a service to facilitate MOC recordkeeping. Time-limited certificates in radiologic physics were issued for the first time in 2002, however, the all components of MOC were not put in place until 2006. Diplomates with cycles beginning before 2006 have prorated requirements. The lifelong learning credit and PQI requirements have been reduced proportionately in these cycles, so diplomates are not required to "catch up" for years before 2006. The specific requirements for each of these cycles are posted on the ABR website. The descriptions below include a brief rationale and specific examples of the five areas targeted to improve the quality of care. This is a "work in progress," and the examples here are provided to help the diplomate understand the process. Note that the minimum requirement is satisfactory completion 4

of one PQI project per MOC cycle. However, if the goals of a project are achieved readily, the diplomate will be encouraged to select and participate in another quality improvement project. Safety for Patients, Employees and the Public All radiologic physicists are concerned with the safety of patients, employees, and the public in their practices. Examples of parameters that could be measured include radiation dose (especially in vulnerable patient groups such as pediatric patients or women of child-bearing age), MR safety, and error prevention. After the baseline data are gathered and performance improvement opportunities are identified, the performance improvement plan must be crafted. Once the plan is implemented, the diplomate simply follows the PQI template (see Table 1). Accuracy of Analyses and Calculations Another characteristic of competent radiologic physicists is that the analyses and calculations in reports have a high degree of accuracy. A PQI project in this category should be easily implemented and generate results suitable for entry into a national registry for comparison with other radiologic physicists. One concrete example of such a project is double reading of selected calculations. A verification project can be performed with validity in a variety of ways. A radiologic physicist could compare his or her results with another radiologic physicist in the practice; for example, by comparing rendered values obtained under similar conditions (peer review). A project studying accuracy of analyses and calculations should include such metrics as the error rate, an analysis of root causes of those errors, and a plan to minimize the errors identified in the project. Additionally, such a project should quantify not only the number of changes in analyses and calculations by the verifying physicist but also the significance of those changes. Projects in this category could be designed by individual diplomates or by subspecialty societies. Report Turnaround Times and Communication Issues Physicians and administrators act on analyses and calculations as they utilize the reports to help them manage their facilities and patients. Thus, it is important to provide analyses and calculations in a timely fashion and to communicate the results effectively. The times that are appropriate for these reports vary with the clinical setting. The report turnaround time is defined as the time between completion of the activity and the time when the final report is made available to the physician or administrator. A PQI project on report turnaround times and communication issues would include collection of baseline data for the individual radiologic physicist. A plan to improve the turnaround times and the efficiency of communication should then be articulated in written form with a description of measures to improve the performance. Data should be collected a second time, approximately two to three years after the first data set. A second improvement plan should then be developed based on the results evident in the second data collection. Practice Guidelines and Standards 5

Choosing this Practice Quality Improvement category requires that the diplomate select a project based upon any of the physics-related ACR Practice Guidelines and Technical Standards, ACMP Technical Standards, and AAPM Reports. For each practice guideline, after analysis of the results, a plan for improvement is formulated. Subsequently, a second data collection period determines the effectiveness of this plan (Table 1). Surveys Radiologic Physics services are usually performed for patients, referring physicians, or administrators. The radiologic physicist contributes to care of the patient by accurately conducting physics evaluations and reporting the findings promptly. The experience of the referring physician or the administration's interactions with the radiologic physicist can be assessed through satisfaction surveys. Surveys may be developed by an individual or by national professional societies. Surveys developed by societies must be qualified by the ABR. Peer review of self-assessment reports would constitute an additional category of survey instruments. A survey designed to evaluate satisfaction with service would include the following parameters: accessibility of the radiologic physicist for examinations or procedures, responsiveness for urgent examination consultation, professionalism, report turnaround time and satisfaction of the referring physician or administration. As with other projects, analysis of the responses should lead to an improvement plan which, after initiation, should be evaluated using the same survey instrument after a suitable time period. As an example, the AAPM is developing a survey instrument for use by medical physics educators through which their students can evaluate the instructors' performance. The ABR and MOC Dramatic change has occurred in the relationship of the diplomate to the ABR. In the past, interaction occurred only through activities associated with the three (3) examinations: Part 1, Part 2, and oral. Now, the relationship between a radiologic physicist and the ABR will begin during graduate education and be continuous throughout his or her professional life. The lifetime relationship will be maintained through frequent electronic communication of MOC updates, key milestones concerning the diplomate's progress through the MOC cycle, and reminders to increase activity should the diplomate be falling behind in a given area. Evolution of the ABR Infrastructure The ABR is committed to providing a web-based system for diplomates to use both to access current information about maintenance of certification requirements and to record their progress. The ABR web site enables diplomates to access specialty-specific information and resources about MOC, the four components, six competencies, and all requirements, examinations, and fees. The passwordprotected ABR Personal Data Base (PDB) is each diplomate's center for personalized information about MOC requirements and for tracking and documenting MOC progress. Within his or her PDB, the individual will be able to record participation in educational activities; attest to the fulfillment of various requirements, such as participation in PQI projects; update personal information; pay fees; and register for examinations.

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Future plans call for linkages between the ABR and societies sponsoring continuing education credit, Self-Assessment Modules (SAMs), and PQI projects. These linkages, undertaken with permission of the society and the individual diplomate, will allow for the transmission of credits and PQI participation directly into the individual's ABR personal data base. These entries will be regarded by the ABR as authenticated (in the case of an audit, no further documentation will be required). The Role of Specialty Societies The specialty societies for radiologic physics will play an important role as they serve their members by advancing the science and practice of their subspecialty, and inform them on regional and national issues relevant to their practice. The societies know the key components of their practices and stimulate the promotion of quality in practice. Their multiple and potentially expanded roles include, but are not limited to, educational courses and Self-Assessment Modules (SAMs) concerning PQI, workshops on subtopics of PQI, identification of key PQI focus areas and development of potential metrics, tools or project templates for their members. Development of national databases related to practice parameters in radiologic physics is an important future goal in collecting PQI data. National databases of practice parameters represent a valuable tool for optimizing the practice of medical physics, because they allow each physicist to benchmark his or her own personal practice. The need for pooled, anonymized PQI results to allow benchmarking presents an opportunity for collaboration among societies related to medical physics to establish national databases for the benefit of our specialty and, ultimately, contribute to improved patient care.

Summary and Conclusions There is a national imperative to measure what all medical professionals do (including radiologic physicists) as their activities impact patient outcomes. Quality improvement principles suggest that when activities are measured and compared to benchmark data and practice components are standardized such that they target and maintain specific improvements, the quality of patient care improves. Radiology, of which radiologic physics is part, has lagged behind some of the other medical specialties in measuring what is done and documenting its impact on overall quality of care. With Practice Quality Improvement as a new initiative within the MOC program, radiologic physicists have the opportunity to document and improve their practice. PQI is the final component of MOC to be developed. While aspects are still best described as "works-in-progress," considerable progress has been made in understanding the charge and identifying ways to use common practice metrics to enhance an individual's practice of radiologic physics. In summarizing the state of the effort at this point in time, the goal is to provide a broad understanding of the PQI program and encourage active participation of all certified radiologic physicists ­ those who have and will automatically enter MOC upon successful completion of their initial certifying examinations and those holders of lifetime certificates who wish to engage in a personally rewarding, publicly visible process for ongoing quality improvement.

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Table 1. PQI Timeline & Milestone Tracking for Radiologic Physics Diplomates

Year of Cycle 1 2 3 4 5 6 7 8 9 10

A guideline of what might be done each year of the ten-year MOC cycle

· · · · · · · · · · · Quality improvement education (first cycle) Select project and metrics Collect baseline data Analyze data Create improvement plan Implement improvement plan Might include data collection Collect data Compare to initial baseline Summarize, draw conclusions Modify improvement plan for previous project or select new project and metrics · Collect baseline data · Analyze data · Create improvement plan (if new project) · Implement improvement plan · Might include data collection · Collect data · Compare to initial baseline · Summarize, draw conclusions Cycle concludes

Table 2. Categories of PQI Projects 1 2 3 4 5 Safety for patients, employees, and the public Accuracy of analyses and calculations Report turnaround times and communication issues Practice guidelines and standards Surveys

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References L.T. Kohn, J.M. Corrigan, M.S. Donaldson, eds. "To err is human: Building a safer health system," Washington, DC: National Academy Press, 2000. 2 "Crossing the quality chasm: a new health system for the 21st century," Institute of Medicine: Committee on Quality of Health Care in America, Washington, DC: National Academy Press, 2001. 3 E.A. McGlynn, S.M. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, E.A. Kerr, "The quality of health care delivered to adults in the United States," NEJM 348, 2635-2645 (2003). 4 S.H. Miller, "ABMS' Maintenance of Certification: The challenge of continuing competence," Clin. Orthop. Relat. Res. 449, 155-158 (2006). 5 C.K. Cassel, E.S. Holmboe, "Credentialing and public accountability: A central role for board certification," JAMA 295, 939-940 (2006). 6 T.A. Brennan, R.I. Horwitz, F.D. Duffy, C.K. Cassel, L.D. Goode, R.S. Lipner, "The role of physician specialty board certification status in the quality movement," JAMA 292, 1038-1043 (2004). 7 American Board of Medical Specialties. "Initiatives recommended by the ABMS Task Force on Competence: Description of the competent physician, Evanston, IL (1999). 8 R. Steinbrook, "Renewing board certification," N. Engl. J. Med. 353, 1994-1997 (2005). 9 S.J. Swenson, C.D. Johnson, "Radiologic quality and safety. Maping value into radiology," J. Am. Coll. Radiol. 2, 992-1000 (2005). 10 J.E. Madewell, R.R. Hattery, S.R. Thomas, L.E. Kun, G.J. Becker, C. Merritt, L.W. Davis, "Maintenance of certification," Am. J. Roentgenol. 184, 3-10 (2005). 11 J.E. Madewell, R.R. Hattery, S.R. Thomas, L.E. Kun, G.J. Becker, C. Merritt, L.W. Davis, "Maintenance of certification," Radiology 234, 17-25 (2005). 12 S.R. Thomas, W.R. Hendee, B.R. Paliwal. "The American Board of Radiology maintenance of certification (MOC) program in radiologic physics." Med. Phys. 32, 263-267 (2005).

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APPENDIX 1 Source Documents Radiologic Physics Practice Quality Improvement

I. Practice Guidelines and Technical Standards A. ACR--Medical Physics Practice Guidelines [http://www.acr.org] 1. Diagnostic Reference Levels in Medical X-ray Imaging (2002) 2. Electronic Medical Information Privacy and Security (2004) 3. Determinants of Image Quality in Digital Mammography (Oct 2007) 4. Digital Radiography (Oct 2007) 5. Electronic Practice of Medical Imaging (Oct 2007) B. ACR--Medical Physics Technical Standards [http://www.acr.org] 1. Diagnostic Medical Physics Performance Monitoring of Radiographic and Fluoroscopic Equipment (2006) 2. Management of the Use of Radiation in Fluoroscopic Procedures (2002) 3. Diagnostic Medical Physics Performance Monitoring of Computed Tomography (CT) Equipment (2002) 4. Diagnostic Medical Physics Performance Monitoring of Magnetic Resonance Imaging (MRI) Equipment (2004) 5. Diagnostic Medical Physics Performance Monitoring of Real Time Ultrasound Equipment (2004) 6. Medical Nuclear Physics Performance Monitoring of Nuclear Medicine Equipment (2003) 7. Medical Nuclear Physics Performance Monitoring of PET Imaging Equipment (2006) 8. Medical Nuclear Physics Performance Monitoring of PET-CT Imaging Equipment (2006) 9. Performance Radiation Oncology Physics for External Beam Therapy (2004) 10. Performance of Brachytherapy Physics: Intravascular Applications Using Catheter-based Systems (IVBT) (2002) 11. Performance of Brachytherapy Physics: Manually Loaded Temporary Implants (2002) 12. Performance of Brachytherapy Physics: Remotely Loaded HDR (High Dose Rate) Sources (2005)

II. Source Documents for Diagnostic Radiologic Physics (Examples) A. AAPM Reports [http://aapm.org/pubs/reports] 1. Acceptance Testing of Magnetic Resonance Imaging Systems - Report No. 34 (1992) 2. Recommendations on Performance Characteristics of Diagnostic Exposure Meters - Report No. 35 (1992) 3. Managing the Use of Fluoroscopy in Medical Institutions - Report No. 58 (1998) 10

4. Real-time B-mode Ultrasound Quality Control Test Procedures - Report No. 65 (1998) 5. Cardiac Catheterization Equipment Performance - Report No. 70 (2001) 6. Quality Control in Diagnostic Radiology - Report No. 74 (2002) 7. Practical Aspects of Functional MRI - Report No. 77 (2002) 8. Acceptance Testing and Quality Control of Photostimulable Storage Phosphor Imaging Systems ­ Report No. 93 (2006) B. National Council on Radiation Protection and Measurements (NCRP) [http:nrcppublications.org] 1. Structural Shielding Design and Evaluation for Megavoltage X- and Gamma-Ray Radiotherapy Facilities ­ Report 151 (2005) 2. A Guide to Mammography and Other Breast Imaging Procedures - Report 149 (2004) 3. Structural Shielding Design for Medical X-Ray Imaging Facilities Report 147 (2004) III. Source Documents for Therapeutic Radiologic Physics (Examples) A. AAPM Reports [http://aapm.org/pubs/reports] 1. Comprehensive QA for Radiation Oncology ­ Report No. 46 (1994) 2. Radiation Treatment Planning Dosimetry Verification ­ Report No. 55 (1995) 3. Quality Assurance for Clinical Radiotherapy Treatment Planning - Report No. 62 (1998) 4. Protocol for Clinical Reference Dosimetry of High-Energy Photon and Electron Beams - Report No. 67 ( 1999) 5. AAPM Protocol for 40-300 kV X-ray Beam Dosimetry in Radiotherapy and Radiobiology - Report No. 76 ( 2001) 6. Guidance Document on Delivery, Treatment Planning, and Clinical Implementation of IMRT - Report No. 82 (2003) 7. Quality Assurance for Computed Tomography Simulators and the Computed Tomography Simulation Process - Report No. 83 ( 2003) 8. Tissue Inhomogeneity Corrections for Megavoltage Photon Beams Report No. 85 (2004) 9. Diode in Vivo Dosimetry for Patients Receiving External Beam Radiation Therapy ­ Report No. 87 (2005) 10. AAPM Task Group 103 Report on Peer Review in Clinical Radiation Oncology Physics ­ Report No.103. J Appl Clin Med Phys (JACMP) 6:50-64, 2005. 11. Intraoperative Radiation Therapy Using Mobile Electron Linear Accelerators ­ Report No. 92 (2006) B. Other Documents 1. J. Van Dyk, R. Barnett, J. Cygler, and P. Shragge, "Commissioning and quality assurance of treatment planning computers," Int. J. Radiat. Oncol., Biol., Phys. 26, 261-273 (1993) 2. Technical reports series No. 430: Commissioning and quality assurance of computerized planning systems for radiation treatment of cancer. International Atomic Energy Agency, Vienna, 2004. 11

IV. Source Documents for Medical Nuclear Physics (Examples) A. AAPM Reports [http://aapm.org/pubs/reports] 1. Radiolabeled Antibody Tumor Dosimetry ­ Report No. 40 ( 1993) 2. Quantitation of SPECT Performance ­Report No. 52 (1995) 3. AAPM Task Group 108: PET and PET/CT Shielding Requirements ­ Report No. 108 (2006) B. NEMA (National Electrical Manufacturers Association) Reports [http://www.nema/stds/] 1. Performance Measurements of Scintillation Cameras NU 1 ­ 2001 2. Performance Measurements of Positron Emission Tomographs NU 2 2007 V. Source Documents for General Medical Physics A. AAPM Reports [http://aapm.org/pubs/reports] 1. Academic Program Recommendations for Graduate Degrees in Medical Physics ­ Report No. 79 (2002) 2. Essentials and Guidelines for Hospital-based Medical Physics Resident Training Programs ­ Report No. 90 (2006) VI. Statistical Process Improvement.

1. Statistical Process Control, Fifth Edition (paperback) by John S. Oakland. Publisher: Butterworth-Heinemann; 5th edition (April 16, 2003). ISBN ­ 10: 0750657669. ISBN ­ 13: 978-0750657662. 2. Introduction to Statistical Quality Control, (hardcover) by Douglas C. Montgomery. Publisher: John Wiley & Sons; 5th edition (August 10, 2004). ISBN ­ 10: 0471656313. ISBN ­ 13: 978-0471656319. 3. Statistical Process Control for Health Care, (hardcover) by Marilyn K. Hart, Robert F. Hart. Publisher: Brooks Cole; 1 edition (September 27, 2001). ISBN ­ 10: 053437865X. ISBN ­ 13: 978-0534378653. 4. The Six Sigma Handbook: The Complete Guide for Greenbelts, Blackbelts, and Managers at All Levels, Revised and Expanded Edition, (hardcover) by Thomas Pyzdek. Publisher: McGraw-Hill; 2nd revised edition (March 20, 2003). ISBN ­ 10: 0071410155. ISBN ­ 13: 978-0071410151. 5. Design for Six Sigma for Service (Six SIGMA Operational Methods), (hardcover) by Kai Yang. Publisher: McGraw-Hill Professional; 1 edition (June24, 2005). ISBN ­ 10: 0071445552. ISBN ­ 13: 978-0071445559. 6. Six Sigma Beyond the Factory Floor: Deployment Strategies for Financial Services, Health Care, and the Rest of the Real Economy, (hardcover) by Ron D. Snee, Roger W. Hoerl. Publisher: Prentice Hall (October 22, 2004). ISBN ­ 10: 013143988X. ISBN ­ 13: 978-0131439887.

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