Invited Article: Neurology and quality improvement

This article is an introduction to a Neurology® series on quality and safety. It is intended to provide a general background on the quality improvement movement in health care along with an introduction to some of the major issues that are currently important. Issues introduced will be developed in greater detail in future articles.

QUALITY IMPROVEMENT: A HISTORICAL PERSPECTIVE

Since its inception over 100 years ago, the application of quality improvement (QI) has polarized the stakeholders in medical care. In 1914, Ernest Amory Codman, a surgeon at the Massachusetts General Hospital (MGH), established the first morbidity and mortality conferences.¹ He wanted to compare morbidity and mortality results between institutions. MGH management not only refused, but revoked his staff privileges, forcing his resignation. He responded by starting his own private hospital, the End Result Hospital, and published outcomes and error data on 337 patients from 1911 to 1916.² Subsequently, he was a founder of the Hospital Standardization Program, which eventually became The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]).

Adoption of formal QI principles in health care did not occur until decades after they were developed. Leaders of manufacturing and service industries, keen to obtain a competitive advantage, formalized the principles of continuous quality improvement (CQI) and total quality management (TQM) in the 1940s. Formal QI did not enter healthcare until the 1980s, when the JCAHO mandated QI and performance measures (outcomes and process) for hospital accreditation.^3–7 By the 1990s, QI entered the outpatient arena, as some managed care organizations (MCO) began basing payments to primary care practitioners, in particular, on performance measures such as immunization rates, mammography screening, and other Health Plan Employer Data and Information Set or HEDIS performance measures criteria. Use of HEDIS measures, initially designed for use by purchasers and MCOs, is now …