In this era of rapidly changing medical practice, it may appear to some
that efforts to improve the quality of medical care are a relatively new development.
In fact, current methods to enhance quality, like all of medical practice,
have evolved. Although the modern conceptual framework of quality measurement,
based on structure, process, and outcome, was introduced by Donabedian1 more than 30 years ago, the struggle to improve medical
care has been protracted. Scholars as ancient as Hippocrates recognized the
critical necessity for not only a knowledgeable physician but also for a coordinated
delivery system and a scientific basis for practice. 2
Likewise, in Osler's Modern Medicine (1907),3 in which the absence of an effective treatment for
lobar pneumonia is readily acknowledged, the authors plead for controlled
studies with adequate sample sizes and detailed information on covariates:
"age, sex, social circumstances and habits; the environment, character of
the epidemic, season of the year . . . and many other details must be constant
features in the groups of cases arranged for comparison." Around the same
time, Codman4 proposed that hospitals track
every patient for a time sufficient to ascertain whether treatment was effective,
foreshadowing today's outcomes management programs.
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