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

During the past century, manufacturing industry has achieved great success in improving the quality of its products. An essential factor in this succe ss has been the use of Waiter A Shewhart's pioneering work in the economic control of variation, which culminated in the development of a simple yet p owerful graphical method known as the control chart. This chart classifies variation as having a common cause or special cause and thus guides the use r to the most appropriate action to effect improvement. Using six case stud ies, including the excess deaths after paediatric cardiac surgery seen in B ristol, Uh, acid the activities of general practitioner turned murderer Har old Shipman, we show a central role for Shewhart's approach in turning the rhetoric of clinical governance into a reality.