Third Edition

Q Solutions: Essential Resourcesfor the Healthcare Quality Professional

I nformation ManagementRobert J. Rosati, PhD

NATIONAL ASSOCIATION FOR HEATTHCARE @AIITY

Glenview; IL

Other titles in the Q So/ufions Suite

L e ader ship and Manqement

Quality and P erformance Improv ement

Healthcare Safety

Regulation, Accreditation, and C ontinuous Reodiness

Copyright @ 2OI2 by the National Association for Healthcare Quality. All rights reserved.

Except as permitted under the United States Copyright Act of 1976, no part of this

publication may be reproduced or distributed in any form or by any means, including but

not limited to the process of scanning and digitization, or stored in a database or retrieval

system without the prior written permission of the publisher.

Copyright O 2005,2008, 2Ol2by the National Association for Healthcare Qualiry.All rights reserved. First edition published in 2005. Second edition published in 2008.

ISBN 978-0-9858 336-3-3

National Association for Healthcare Quality47OO W. Lake AvenueGlenview IL 60025www.nahq.org

For the National Association for Healthcare QualiryStacy Sochacki, Executive DirectorBeth Zemach, Senior Programs and Product AnalystKaren Schrimmer, Practice Content Manager

June Pinyo, MA, ManagingEditorMonica Piotrowski, Associate EditorSonya Jones, Senior Graphic Designer

Printed in the Unitedstotes of America

ThirdEdition

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Contentsl.HistoricalPerspective,Background,andCurrentlnitiatives ........,

A. QualityManagementPhilosophy. ......1B. EarlyStrategiesof Managing forQuality ....... 1

t. World War lland lts lmpact ........ ..2z- The Japanese Quality Revolution and lts lmpact . . . . . .2

C. QualityManagementPioneers. ........3l-Shewhart. ...........j2. Deming. ....,45.Juran ........54.Crosby. ......5s.lshikawa. ............6

D. Healthcare Quality Management Pioneers. .....61. The FirstEra: Nightingale, Codman, and theAmerican College of Surgeons ..........62.TheSecondEra,DonabedianandTheJointCommissioniMonitoringandEvaluationProcess.........T

5.TheThird Era: Berwick, Batalden, andJames "Discover" Deming, Juran, and'Japan,lnc." .. ...........7E. Current and Evolving Healthcare Quality Management Approaches . . . . . I

t.SixSigma ...........82. Lean Enterprise ......g5. Reenginee.ing .. .....9a. Rapid Cycle lmprovement . ...... .. .tO

F. FocusonPatientSafety. ...... 10

G. Patient-Centered Care.. .... . . .11

H. TeamSTEPPS'". ... . .. .11

ll. IOM lmperatives, Priorities, and Compefencies . . . . .12

A. PatientSafetyand Harm ......12B. Changing the Healthcare Delivery System . . . . . 12

C. PolicyandHealthcareQuality. ........ 13

lll. PublicReportingandRewardingforQuality ........14A. PublicReporting ......14B. RewardingforQuality ........14

lV Confidentiality Principles, Privacy, and Patients' Rights and Responsibilities. . . . .16

A. Conftdentiahty . .. .. . . t6

l.Releaseof lnformation..... ........182.Authorized Releaseof lnformation..... ......l8

B. MedicalPeerReview .........19C. Utilization Management ... . .. t9

1. lnternal Review. . .. . .19

2. ExternalReview .....19D. MedicalRecords/ElectronicHealth Records(EHR, ..........20

l.lnformation Covered by Privilege . .. 20

2. Patients'Billof Rightsand Responsibilities ...........21

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V. Evidence-Based Quality Management ... ..... ... '21A. TheQualityManagementResearch Continuum .......21B. Evidence-Based Practice . . .. .... .. ' .23

C. Applying Epidemiological Principles to Ql . - - - - 23

Vl. Measurement, Decision Support, Risk Adjustment,Data lnterpretation, and Benchmarking . . .. . .24

A. DecisionSupport .....24B. RiskAdlusrment. .....25C. Analysis and Interpretation of Outcomes Data and Decision-Support Tools . . . . .26

D. Benchmarking... .....27

Vll. Systematic Heahhcare Quality .. . . . . 28

A. Developmentof a Quality lnformation System ........28B. StrategyforlnterpretationandUseof lnformation .. ..........30

Vlll. Management lnformation Systems .. . .32

A. Purposesof lnformationSystems ......33t. Clinicallnformation Systems ........342.AdministrativeSupportlnformationSystems. ........343. DecisionSupportSystems ..........34

B. lmplementationof a QualityManagementlnformationSystem ........351. EvaluatingSystems .........352.Selecting a Quality ManagementSystem ...........35

C. FederalHealth lT lnitiatives. . .........36

lX.QlStudyDesignandAnalysis .......58A. Getting Started on QPI Projects .. . . .. 38

B. DataandDataManagement ..........391. Categorical...... ..........392.Continuous...... .........403. Statistical Power of Different Data Types . . . . 40

C. Data Collection Plan . . ...... .4O

D. BasicSamplingDesigns .......411. Types of Sampling ..........41

a. Probability ......41b. Nonprobability .. ...... . 41

2.SampleSize.. ......42E. DataAnalysis. ........42

l. Reporting ..........422. lmportanceof Context ......43S.Variation ...........434.Tiend ldentification .........43

F. StatisticalAnalysisand lnterpretationof Findings ......431. MeasurementTools .........432.Reliabiliry ..........43

a. ReliabilityCoefficient. ..........43b. lnterraterReliability .....44

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:. Validity .... 44

a. Content(Face)Validity..... ....44b. ConstructValidlty ......44c. Criterion-RelatedValidity ..... .........44

4.StatisticalTechniques .......45a. Measuresof Central Tendency ..........451) Mean. ......452) Median. .....453) Mode. ......46

b. Measures of Variability. . . . .. .. . .46

1) Range, ......462) StandardDeviation. .........46

c. lnterpercentile Measures..... -. ----.-..47S.Tests of StatisticalSignificance. .... '.47

a. ParametricTests.. ......48b. NonparametricTests ....49

6. Concepts Related toTests of Significance..... ... ' ' 50

a. Confidencelntervals ....50

b. Levelof Significance..... ...'..51G. PerformancelmprovementTools ...." 51

1. Decision-Making MethodsandTools ........512. Data Analysis and Process Improvement . . . . .57

3. Statistical Process Control ....... '..62

a.Typesof Variation ----.....64

X. Summary . . ..... 70

References

Suggested Reading.

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74

Online Resources .... .76

lndex. ..... . .. .79

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TablesTable 1.

Gble 2.

Table s.

Table 4.

Table s.

Comparison of Six Sigma Breakthrough Strategy and Juran! Problem-Solving Strategy . . . . . 9

Research ProcessVersusQl Process. ......21Examples of Benchmarking Projects. . . . . . 28

StatisticalOptionsforDifferentDataTypes ......48Statistics ReferenceTable.. ......50

FiguresFigurel. TheTiaditionalPlan-Do-Check-ActModel . ......4Figure2. QualityMovementTimeline ......6Figure 3. Health lnsurance Portability and Accountability Act of pga. . . . . , , .18

Figure4. Patients'Billof Rightsand Responsibilities. .......22

Figure6. Brainstorming ....52FigureT. Multivoting. .....52FigureS. NominalGroupTechnique. ......53Figure 9. Activity Network Diagram .. .. . . . 55

Figure1O. DeploymentChartorPlanningGrid .. ..........54Figure11. StratificationCharts .....55Figure12. HistogramorBarChart .........56Figurel5. ParetoDiagramorChart ........58Figure14. Cause-and-Effect,lshikawa,orFishboneDiagram ........59Figure15. ScatterDiagramorScatterPlot... .......60Figure16. Healthcare FailureModeand EffectsAnalysis(HFMEA) .........60Figure lT. Affinity Diagram . . . .. .. . .61

Figure18. lnterrelationship Diagram. .......62Figure 19. Tree Diagram .... 63

Figure2o. MatrixDiagram..... ....64Figure21. PrioritizationMatrix. .....65Figure22. Flowchartor Process Flowchart. .........66Figure23. ProcessDecision ProgramChart(PDPC) .........67Figure24. RunChartorTrendChart. ......68Figure25. ControlChart. .........69Figure26. ForceFieldAnalysis .....69Figure27. Frequency Distribution. .........7O

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Foreword to the Third EditionHealthcare is at a transformative and exciting time as we embark on new models of deliv-

ering care. Prominent focal points during this essential time are quality, safety, innovation,

and the technology needed to bring higher levels of performance with lower costs. During

2otl and 2012, the National Association for Healthcare Quality (NAHQ) has been prepar-

ing for the transition by reenergizing our purpose and vision and solidifying our strategies

for meaningful work that benefits our stakeholders. Our challenge is determining how to

provide the greatest value to our members, certificants, and consumers of NAHQ products

while continuing to expand our reach.

We believe it to be of primary importance to coordinate the work of the NAHQ Board

of Directors, staff, and teams, as well as the Healthcare Qualiry Certification Commission

(HQCC) to ensure NAHQ products are ready for the market previotts to when programs are

offered. A prime example of the effort is the third edition of Q Solutfons.

I take this opportunity to personally thank Luc R. Pelletier, MSN PMHCNS-BC CPHQ

FNAHQ FAAN, and Chrisry L. Beaudin, PhD LCSW CPHQ FNAHQ, for leading this major

revision to Q Solurions with the most current information available. By providing continuity,

intellectual capital, and fortitude to this important NAHQ goal, we have the product ready

to deliver to you. The NAHQ Board called on a number of key people throughout the coun-

try to support the writing and review of the content, which coordinates with the Certified

Professional in Healthcare Quality (CPHO content outline's main divisions. I thank each ofthem and the NAHQ staff for helping to bring this valuable resource to market.

This edition of Q solurions features a new approach to presentating content. By placing

the information within individual modules, purchasers may obtain a module specific to his

or her needs. The availabiliry of the first four modules (and fifth module soon after) of the

third edition coincides with updates to the United States regulation and accreditation con-

tent HQCC will begin using in January of ZOt3. I am certain all of you will \r/ant to share this

updated resource with your colleagues in the field of healthcare quality. These resources

will motivate you to excel even further.My career development and leadership style have been enriched by many individuals,

especially those who have brought their best into this wonderful organization. NAHQ con-

stituents are my network for identifying, learning about, and understanding changes that

are happening rapidly and continuously within care delivery. They enhance their work-

places, and patients benefit from their commitment to achieving healthcare improvement.

Promoting safe, effective, and efficient practices through education, certification, and ad-

vocacy are key components. I encourage each of you to identify the strengths in the people

and the products of NeHq. Enjoy the third edition of Q Solurions.

Betry Brown, MBA MSN RN CPHQ FNAHQNAHQ President, 2O|L-2OL2

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PrefaceHealthcare is complex and at times confusing to customers. Delivery systems, health plans,

solo and group practitioners, employers, and government agencies seek ways to achieve the

Triple Aim-ensure quality of care for the individual, improve the health of the population,

and control costs. Developing, deploying, and sustaining appropriate quality strategies

pose challenges and opportunities for healthcare quality professionals. Thoughtful

strategies employ effective, efficient, and evidence-based approaches to measure, monitor,

and determine outcomes. Did the actions and interventions yield intended goals and

objectives for improved qualiry and performance excellence? The healthcare quality

professional must successfully navigate the system to demonstrate quality and safety. The

application of sound theoretical and methodological practices is imperative. Q Solurions

covers the breadth and depth of critical areas for professional development and leadership,

including frameworks for quality management, the linking of science with practice, and

the translation of data into practical information that can be used and understood by any

customer, whether it is a practitioner, third-party payer, or consumer.

The development of the third edition of Q Solutions was informed by the most recent

Healthcare Qualiry Certification Commission's (HQCC's) practice analysis. The practice

analysis assesses the current functions and competencies for certified professionals in

healthcare qualiry. Organized under the HQCC detailed content outline, the following

modules were created:, Leadership andManagement

. quality andPeformance Improvement

. Healthcare Safety

. Information Management

. ReSu lat ion, Accre ditation, and C ontinuous Readiness.

These modules feature critical components of healthcare qualiry the science and art

of quality and performance management, and environmental considerations such as

healthcare reform. In addition, Q Solutions was developed using feedback from healthcare

quality professionals and academic and policy experts in the field.

In our world of teeming technology, rapid innovation, and continuously expanding

science, we also rely on hope day in and day out. We hope that political agendas will reflect

the needs of patients, families, and other stakeholders; that resources will be available forthe work to be done; and that fear will not result in barriers to uncovering mistakes, flaws,

and failures. For healthcare qualiry to permeate the healthcare landscape, the cultures ofsilence that still exist in institutions must be eradicated.

In addition to emerging technologies and techniques, the foundation of our work

involves the collaborative relationships we form and develop with various stakeholders.

Our work, after all, is relationship based. Mutual respect and accord lead to mutual

understanding and a sense of camaraderie as we face complex healthcare qualiry

challenges. This is accomplished in many ways including affiliations with professional

groups such as the National Association for Healthcare Qualiry (NAHQ).

Q Solurions is targeted to audiences across the care continuum and provides critical

knowledge to develop and enhance essential leadership skills in healthcare quality. Ineffect, these tools and techniques are universal to any healthcare setting. The basic

principles can be adapted to your organization. When we embarked on the third editionjourney, there was no question about who the right people were to make these publications

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happen. We were humbled by the company we kept. Fortunately, these individuals made

time for what proved to be a fruitful endeavor. The product you hold in your hands wouldnot have been possible without the unceasing efforts of our esteemed authors-Cathy E.

Duquette, PhD RN CPHQ NEA-BC; Robert Rosati, PhD; Sr.rsan V. White; PhD RN CPHQNEA-BC FNAHQ; and Diane S. Brown, PhD RN CPHQ FNAHQ FAAN. Their visionfor NAHQ is depicted on every page. We thank them all for their thoughts and ideas

throughout the development process. In addition, we appreciate the thorough contentexaminaticln by our external review panel members-James B. Conway, MS LFACHE;Gerald N. Glandon, PhD; John Hansen, MD MPH; Bernarcl J. Horak, PhD FACHE CPHQ;and Barbara G. Rebold, MS RN CPHQ. As always, we acknowledge the continuous supportof the NAHQ Board of Directors, which has resulted in the successflil launch of the thirdedition of Q Solutions.

The work of healthcare quality professionals is noble indeed. Armed with a set ofadvanced skills and practical tools, we are a force that can be boundless. Our nobiliry comes

from the fact that we are truth seekers. We are constantly challenged to tell a quality storythat is cogent, accurately depicts healthcare circumstances, and is understood by varyingaudiences. To be able to tell the truth, we must demand that healthcare organizations

. provide resources necessary to conduct investigations and to maintain reportingsystems that use state-of-the-art information technologies;

. allow and support a solid infrastructure for continuoLls readiness, including health

information technology that supports the continuous quality improvement paradigrn

and doesn't disappear after an accreditation survey or regulatory audit;

. ensure that all organizations are educated on the science of discovery (i.e., data,

methods, analysis, and application); and

. contribute to the growing body of healthcare qualiry science by sharing evidence-

based, outcomes-oriented qualiry techniques making a difference in the safety, care,

and service embraced by forward-thinking, highly reliable organizations.

Our primary goal for this suite of Q So/urions modules is to provide NAHQ members

and other qualiry and patient safety professionals with a product that is reliable, valid,

innovative, and timely. These updated modules reflect recent changes in national

healthcare safery as well as the transformation of healthcare as we know it. In the future,

NAHQ plans to supplement these modules with other relevant topics and learning

opportunities.

Luc R. Pelletier, MSN PMHCNS-BC CPHQ FNAHQ FAAN

San Diego, CA

Chrisry L. Beaudin, PhD LCSW CPHQ FNAHQLos Angeles, CA

Q SoluEionsxll

About the EditorsLuc R. pelletier, MSN PMHCNS-BC CPHQ FNAHQ FAAN, is an administrative liaison

at Sharp Mesa Vista Hospital, a core adjunct faculty member at National University, and

a healthcare consultant in San Diego, CA. He received a Master of Science degree in

nursing from Yale University and a bachelor of science in nursing from Fairfield University.

A healthcare quality professional for almost 25 years, Pelletier has participated in local

and national initiatives that ensure safe and equitable care for behavioral health patients

and has helped to shape systems of care and national standards of performance. He has

publishecl several books and written numerous chapters and peer-reviewed articles. He

has delivered presentations on various nursing and healthcare quality topics and given

writing seminars to aspiring authors. He was the editor in chief of the Journal for Heakhcare

Quolity from 1998 to 2007. During his tenure, the journal grew in prominence as a leading

healthcare quality publication and was the recipient of various publishing awards. He has

served as a nurse expert with the U.S. Department of Justice and as a scientific consultant

to the National Institutes of Health. His current research focus is on nurse residency

progt ams in behavioral health and patient engagement. He is also a Fellow of the American

Academy of Nursing and NAHQ.

Christy L. Beaudin, PhD LCSW CPHQ FNAHQ, is national director of quality for AIDS

Healthcare Foundation in Los Angeles, CA. In her current role, Dr. Beaudin is responsible

for healthcare safety, accreditation, infection prevention and control, public reporting, and

education. At the executive level, she led healthcare safety efforts at Children's Hospital

Los Angeles, PacifiCare Behavioral Health, and Value Behavioral Health, and served as

vice president of research and development at Magellan Behavioral Health. Dr. Beaudin

supported hospitals and managed care organizations in preparing for and maintaining

state licensure and accreditation compliance including the National Committee for

Quality Assurance (NCQA), URAC, Accreditation Association for Ambulatory Health

Car.e (AAAHC), and The Joint Commission. Dr. Beaudin earned her doctorate in health

services from the UCLA School of Public Health, master's degree in social work from San

Diego State University, and bachelor's degree in criminal justice from California State

Universiry San Bernardino. Dr. Beaudin is adjunct faculty at the University of Redlands

and participates in state- and national-level quality initiatives for NAHQ, SNP Alliance, and

the California HealthCare Foundation. She is widely published, serves on several editorial

boards and review panels, and is a national subject matter expert on healthcare quality,

behavioral health, and managed care.

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About the AuthorRobert J. Rosati, PhD, is vice president of clinical informatics at the Center for HomeCare Policy and Research, Visiting Nurse Service of New York (VNSNY). At the Center, Dr.Rosati is responsible for directing analysis and reporting of clinical ourcomes for patientsserved by the VNSNY. He created and manages an Intranet website that allows all agencystaff to have access to reports and analyses provided by the Center's Informatics group.The website provides detailed information on patient demographics, qualiry and outcomes,referral sources, and utilization data. Dr. Rosati has more than 2O years' experience inhealthcare in varied research, qualiry management, educational, and administrativeroles. Dr. Rosati is currently on the faculty of Weill Cornell Nledical College and HofstraUniversity. He has published many healthcare quality-related articles and made numerouspresentations at national meetings. Dr. Rosati has been an investigator on externally fundedresearch studies that include United Hospital Fund's Medicaid High-Cost Care Initiative,Working Conditions and Adverse Events in Home Health Care, Patient Safety in HomeCare, and Improving Transitions and Outcomes for Heart Failure Patients through aHospital-Home Care Information Exchange. He also serves on the editorial board of theJ ournal for He akhc are Q uality (JHQ).

External Review BoardThis project could not have been completed without feedback from expert thought leadersin the healthcare quality industry. We thank Dr. John Hansen for providing feedback forthis module.

John Hansen, MD MPHDirector of Quality AccreditationGroup Health Cooperative of South Central WisconsinMadison, WI

AcknowledgmentWe would like to acknowledge Jacqr-reline F. Byers, PhD RN NEA-BC CPHQ FAAN, whoco-authored relevant content in the first two editions of Q .So/utions.

lnformation Management

Learning objectives1. Develop an understanding of activities required for the design and collection of data (e.g., activities,

records, reports and committee meetings).

2. Recognize tools and approaches useful in designing and constructing quality and performanceimprovement activities (e.g., principles of qualitative and quantitative data collection).

5. Apply process analysis tools, basic statistical techniques and methods for statisticaI process control.

4. lnterpret data to support decision making and promote change to advance qLraliry- and performanceexcellence in healthcare.

l. Historical Perspective, Background, and Current lnitiatives

A. Quality Management PhilosophyThe Institute of Medicine (IOM) defines healthcare quality as the extent to which health ser-vices provided to individuals and patient populations improve desired health outcomes.Care should be based on the strongest clinical evidence and provided in a technically andculturally competent manner characterized by good communication and shared decisionmaking (IOM, Committee on Quality of Health Care in America [CQHCA], 2001). As de-

scribed later in this module, total quality management and continuous quality and perfor-mance improvement (QPI) are two strategies for achieving healthcare quality.

Total quality is best defined as an attitude or orientation that permeates an entire orga-nization and the way in which an organization performs its internal and external business.People accept individual responsibility for the quality of their work and elicit genuine com-mitment and active involvement from their organization's leadership. People who work inorganizations dedicated to the concept of total qualiry constantly strive for excellence andcontinuous improvement in all that the organization does. Total qualiry integrates funda-mental management techniques, existing improvement efforts, and technical tools througha disciplined approach and focuses on continuous process improvement.

This definition of total qualiry is applicable to all healthcare settings. Regardless of the reg-ulatory and accreditation standards to which an organization subscribes, leadership principlesremain as fundamental elements of the enterprise's strategic and quality planning. Leadershipis the driving force in creating and supporting the way people think about the things they do.

Leadership establishes the basis for procedures and focuses on customer needs, engagement,and satisfaction. The leadership role must be genuine and visible, with active participation inestablishing, achieving, and rewardingthe attainment of qualiry objectives.

B. Early Strategies of Managing for QualityThe need for quality has always existed. However, the means for meeting that need-theprocesses of managing for quality-have undergone extensive and continuing change (Ju-ran,1977). Before the 20th century managing for quality was based on ancient principlesthat included product inspection by consumers, which is still widely used in today's villages,and marketplaces concept, with which buyers rely on the skill and reputation of trained, ex-perienced craftsmanship. Some craftsmen develop reputations that extend far beyond theirvillage boundaries. They are viewed as lirring national treasLlres.

As commerce expanded beyond village boundaries and with the $owth of technology,additional methods and tools were invented to assist in managing for quality:

. Specifications by sample

. Quality warranties in sales contracts.

2 Q Soluuions

In large towns, the craftsmen organized into monopolistic guilds, which generally were

strict in their enforcement of product quality. Their strategies included. mandated specifications for input materials, processes, and finished goods;

. audits of the performance of guild members; and

o export controls on finished goods.

The early approach to managing for quality in the United States followed the prevail-

ing practice in European countries that had colonized the North American continent. Ap-

prentices learned a trade, qualified to become craftsmen, and in due course might become

masters of their own shops.

The Industrial Revolution, which originated in Europe, created the factory system,

which soon outproduced the small independent shops and made them largely obsolete. The

craftsmen became factory workers, and the masters became factory foremen. Quality was

managed as before, through the skills of the craftsmen, and supplemented by departmen-

tal inspection or supervisory audits. When the Industrial Revolution spread to the United

States, Americans again followed European practice. The Industrial Revolution also accel-

erated the growth of additional strategies, including. written specifications for materials, processes, finished goods, and tests;

. measurement and the associated measuring instruments and testing laboratories; and

. standardization in many forms.

1. World War ll and lts lmpactDuring World War II, U.S. industry was faced with the added burden of producing enormous

quantiiies of military products.Apart of thewar strategywas to shutdown production of many

civilian products such as automobiles, household appliances, and entertainment products.

A massive shortage of goods developed amid a huge buildup of purchasing power. It took the

rest of that decade (the 1940s) for supply to catch up with demand. In the interim, manufac-

turing companies gave top priority to meeting delivery dates, so quality of products suffered.

The practice of givingtop prioriry to delivery dates persisted longafter the shortages ended.

A new strategy emerged during World War II: statistical quality control (SQC). The Warproduction Board, in an effort to improve the qualiry of military goods, sponsored numer-

ous training courses on the statistical techniques developed by the Bell System during the

1920s. (Interestingly, W. E. Deming, who became widely known during the 1980s, was one

of the lecturers at some of the War Production Board courses) Many training course at-

tendees became enthusiastic and organized the American Society for Quality Control (now

known as American Sociery for Qualiry [ASQ). In its early years ASQ was strongly oriented

toward SQC, thereby stimulating further enthusiasm for the method.

As it turned out, most SQC applications in the manufacturing companies were tool-

oriented rather than results-oriented. As long as government contracts paid for everything,

the companies could not lose. In due course the government contracts came to an end and

the SeC proglams were re-examined from the standpoint of cost-effectiveness. Most of

them failed the test, resulting in wholesale cutbacks.

2. The Japanese Quality Revolution and lts lmpact

After World War II, the Japanese embarked on a course of reaching national goals through

trade rather than military means. The major manufactttrers, which had been extensive-

ly involvetl in military production, were faced with converting to civilian products. A ma-

jor obstacle to selling these products in international markets was a reputation for shoddy

merchandise, created by the export of poor-qualiry goods before World War II.