Quality in health care is reaching a pinnacle of exposure with an influx of media attention and response of consumers and providers to the Institute of Medicine's reports on quality and patient safety. The health care industry has just now gained momentum in recognizing and promoting the importance of quality. However, quality in health care found its roots much earlier in history, based upon the presence of two very influential providers, one, a nurse by the name of Nightingale, and the second a physician by the name of Codman.
Florence Nightingale is recognized the world over as a nursing visionary. Her scholarship and work in promoting the science and art of nursing set Nightingale apart from all others in nursing and in health care quality. Nightingale challenged an authoritarian and male-dominated society in England to change health care practices in the Crimean war. Her influence helped to save thousands of lives, and changed health care forever. Basic sanitation and strict adherence to decreasing the spread of infectious organisms, coupled with statistical analysis and graphical presentation on the causes of death, brought scientific evidence to nursing and a face to quality care. This work earned Nightingale her place in history and brought quality care to the forefront of nursing science.
During the same time that Nightingale's work in nursing and health care quality began reaching a peak, physician Earnest Codman entered the scene. In 1914, Codman called for a compilation and analysis of surgical outcomes. He believed that studying what happened to a patient would provide insight into better processes and practices. Codman kept a pocket-sized card, which he called an end results card, on which he recorded each patient's case number, preoperative diagnosis, names of operating team members, procedures and results. He used the cards to study outcomes, the basis for quality improvement. He encouraged his peers to do the same. However, as a man ahead of his time, Codman's call fell upon deaf ears and the local medical society expelled him as its president. Despite such an unexpected and negative outcome, he had planted a seed that helped initiate the American College of Surgeons (Codman, 1934).
Nightingale and Codman were visionaries in the quest for quality in health care. Unfortunately, contemporaries did not readily accept their ideas. However, their work earned them a place in history and sparked the flame for quality that now continues to evolve. Currently, patient outcomes monitoring is taking center stage as consumers and purchasers of health care are beginning to demand proof of results from the services provided. A consumer driven group of Fortune 500 companies, for example, developed the Leapfrog Group and its guidelines requiring evidence of safe, quality practice before purchasing health care contracts for their employees. Payment for service from large employers is having a great impact on the push to prove the existence of high levels of quality in acute care settings.
In addition, the expectations of accrediting agencies, voluntary health care organizations, and local, state, and national regulatory agencies have fostered a focus on providing evidence for quality improvement in the acute care setting. Among the latter are The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), and the American Hospital Association. Recommendations from these groups are made annually regarding best practices, and health care practitioners are being measured using criteria for specific patient populations. For example, the core measures set includes inpatient practice recommendations for heart failure, acute myocardial infarction and community acquired pneumonia. Health care organizations across the country are expected to collect and provide metrics that evidence-based practices are promoting increased adherence to quality processes in health care.
In retrospect, two pioneers in nursing and medicine set the stage for integrating quality processes into the delivery of health care. Nightingale and Codman brought the importance of quality care to light, and today consumers of health care are demanding that the work they began a century ago be continued and expanded, and that quality take center stage in the provision of health care.