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April 5, 2000

The Quest to Quantify Quality

Author Affiliations

Author Affiliations: Veterans Affairs Puget Sound Healthcare System and the Department of Medicine, University of Washington, Seattle.

JAMA. 2000;283(13):1740-1742. doi:10.1001/jama.283.13.1740

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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