The Foundations of Health Care Quality

Common procedures and protocol at our modern day hospital, such as follow up exams and dual diagnostics, was not the case at the turn of the 20th century. During that time, doctors made house visits and there was little desire to monitor patients after treatment. Yet times have changed. Today doctors and physician must follow hospital policies that work to maintain the quality of treatment and care. When an ill person is seen at the hospital in the 21st century things are much different. The patient is examined, diagnosed, given medication, and sent home. These functions are a part of quality care. Nevertheless, as a major part of the hospital experience, quality care has fundamentally changed and improved the quality of patient care seen today.

 Before there was the Joint Commissions, Medicare, and the American Medical Association (AMA), there was Earnest Codman, founder and creator of health care quality. He believed in obtaining quality care and maintaining follow up care with patients during the early 1900’s. At this time, his practices were new, advanced, and unheard of.  A Harvard graduate and surgical physician at Massachusetts General Hospital, Codman was a leader of his time. He strongly believed in continuous follow up care with his patients by keeping records, indicating their diagnosis, treatment, and outcome through a systematic and precise manner. In an attempt to encourage others in his movement, Texas Health Resources states that, “in 1914, Codman called for a compilation and analysis of surgical outcomes”. As a result, he was later terminated from his post for his alternative approach to medicine. However, in 1917, Codman remained undeterred as he later “planted a seed that helped initiate the American College of Surgeons” (Texas, 2011). That same year he created the Hospital Standardization Program. The program provided a list of minimum standards expected from health facilities, which focused primarily on patient care.

With the foundations of health care quality now paved by Codman, through the American College of Surgeons and the Hospital Standardization Program a new entity was formed: The Joint Commission on Accreditation of Health Care Organizations (JCAHCO). In 1951 JCAHO was created by merging several medical associations with the Hospital Standardization Program, including The American College of Physicians, American Hospital Association, American Medical Association, and the Canadian Medical Association.  As a joint commission, JCAHO’s mission is to: “continuously improve health care … by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value”. With this purpose in mind, many hospitals and health care organizations turn to JCAHO’s as means of receiving accreditation and was later granted authority over hospitals in 1965 until 2010. The Joint Commissions then branched out to other health care facilities. This included long term care in 1965, community mental health in 1973, ambulatory care in 1975 and later hospice in 1983.  With JCAHO in place, medical facilities and organizations are forced to meet their expectations and abide by their regulations. These medical facilities are asked to maintain a healthy and safe environment for patients, ensuring they receive the best quality care available.

Avedis Donabedian is another physician who paved the way for health care quality in the United States. A professor in public health, Donabedian wrote an article in 1966 which created a rubric measure on how to evaluate the quality of health care or Health Outcome Research (HOR); defined by Luce, Bindman, and Lee from the University of California at San Francisco as, “the study of the end results of health services”.  Donabedian used three main identifiers to measure health outcome. These include, structure- how doctors and staff provided care, process- the method of care given and how it is provided, and outcome- the end results of care. The end result of care is seen as, whether the patient was cured, succumbed to their illness, or displayed no change. With the introduction of HOR, the Social Security Act in 1935, and the introduction of Medicare in 1966, the Hospital Standardization Program was abandon. This made the federal government now closely involved in health care quality. The government agencies “required additional guidelines as majority of hospitals met and exceeded the minimal requirement” (Luce, Bindman, & Leeas, 1994). Furthermore, “Congress set rules called the ‘Conditions of Participation’ that set principals to hospital operations including twenty-four hour nurses care” (Luce, Bindman, & Leeas, 1994).

The Professional Standards Review Organization (PSRO) was created in 1972 through the Social Security Act.  Its primary function was “to promote efficiency and eliminate unnecessary hospital utilization” (Luce, Bindman, & Leeas, 1994). However, the PSRO was soon eliminated in 1981 due to complaints and allegations that they “emphasized cost containment over quality care” (Luce, Bindman, & Lee, 1994). As a result, the Peer Review Organization (PRO) was developed to take its place. The Peer Review Organization (PRO) was made up of doctors and physicians who reviewed case files at random in search of problems or incidents of quality care. Once a problem was noted, the PRO was able to take disciplinary action including informing the physician of error, re-education, referring the case for additional review, written reprimand to accreditation and licensing, or issuing fines and sanctions. However, due to additional complaints by physicians, in the late 1980’s Congress requested that the PRO “change its scope and modernize its policies” (Luce, Bindman, & Lee, 1994). To create a balancing act between physicians and the PRO, another agency was created in 1992 called the Health Care Quality Improvement Initiative who works as a joint task force with the PRO to review and document incidents of quality care.

When reviewing the history of health care quality in the United States, it is clear that many hands are at play when it comes to our health care system. Many agencies work together to review hospitals, patient care, and reform, in order to maintain structure, safety, and the best services available. With so many different entities involved, it provides a sense of security not only for patients but also for the medical community as well. By having the system of Quality Care in place, many doctors are able to learn about new advances in medicine and more effective ways to treat patients. This information is a valuable resource to our nation and society, as we strive to live a healthier and longer.



A Brief History of Quality. (2011). Texas Health Recourses Inc.[Online] Texas: Quality and Patient Safety. Retrieved from

Luce, J. M., Bindman, A. B., & Lee, P. R. (1994). A brief history of health care quality assessment and improvement in the U.S. Western Journal of Medicine, 160(3), 263-268. Retrieved from

Facts About The Joint Commission. (2011). The Joint Commission Web site. Retrieved from:

Merry, MD, M. D., & Crago, PhD, M. G. (2001). The past, present, and future, or health care quality. The Physican Executive, 30-35. Retrieved from:


About Russia Robinson

I use my writing talents, and skills I’ve learned through academics and experience, to benefit the greater good of society. Conducting research, writing articles, essays, and blogging, I give informative information on a variety of topics and issues that affect society. I also write creative works like children’s books, short stories, poems, and a novel in progress. I earned a BA in English creative writing and American literature from San Francisco State and graduate studies in Technical Writing at Kennesaw State University. Through my career in education and mental health I have spent more than 10 years’ helping young people succeed. I am a certifiable Language Arts teacher, working in education, social services, and mental health. Interested in my writing services? Feel free to contact me via email.
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