This introductory text provides an overview of the article “The history of healthcare quality: The first 100 years 1860–1960”. Published in the International Journal of Africa Nursing Sciences in 2014, the paper is authored by Brenda Helen Sheingold and Joyce A. Hahn from The George Washington University, School of Nursing.
Purpose and Scope: The article serves as Part one of a historical review of healthcare quality development, focusing on the period from 1860 to 1960. It highlights how healthcare quality improvement in this earlier era emerged from a series of “seemingly unrelated incidents and developments” rather than a streamlined, organized effort. The authors sequentially review key international historical events that contributed to improving healthcare quality, including innovations in healthcare financing, care delivery, and workforce diversity. The paper also notes that many of these historical challenges continue to be encountered by the modern nursing workforce globally. To navigate these fragmented historical events in an orderly fashion, the authors utilize Malcolm Gladwell’s theory of “Tipping Point”, which describes phenomena that precede change before it becomes a norm.
Key Areas and Contributions to Healthcare Quality (1860–1960):
- Quality Improvement Documentation: The history of healthcare quality begins with Florence Nightingale, who is described as a “Tipping Point” person due to her rare social gifts. In 1854, during the Crimean War, Nightingale meticulously documented improvements that drastically reduced the mortality rate among British troops from 42.7% to 2.2% within six months of her arrival. Her specific improvements included reducing overcrowding, providing ventilation, removing horses from hospital basements, ensuring sewer flushing, and disinfecting latrines. Her records were crucial for present-day statistical quality measurement, and she was an innovator in data collection, tabulation, interpretation, and graphical display, famously naming her graphical data display a “Coxcomb” (known today as a pie-chart). Nightingale’s work in measuring quality improvement, proper documentation, and generating buy-in for interventions forms the foundation for current international benchmarks of excellence in healthcare.
- Sanitary Commissions: Approximately seven years after Nightingale’s work, the Sanitary Commission was founded in the U.S. in 1861, inspired by lessons from the Crimean War. During the American Civil War, this partnership aimed to promote clean and healthy conditions in Union Army camps and hospitals. Clara Barton, a civilian volunteer, supervised nursing care, and was assisted by Dr. Elizabeth Blackwell, the first female medical school graduate in the U.S., who had previously worked with Florence Nightingale. Sanitary Commission Agents were vital to the Union Army’s success, patrolling camps, inspecting conditions, organizing diet kitchens, and making bandages.
- Improvisation and Innovation: Louis Pasteur, a French chemist, made a monumental contribution by discovering that disease was caused by microorganisms, leading to the “germ theory”. This discovery resulted in the widespread adoption of antiseptic practices and the development of “pasteurization”. Later, during the 1918 Influenza Pandemic, Surgeon General Dr. Rupert Blue provided leadership by implementing quarantine, mandatory medical exams, and communication through newsletters. Dr. Blue is considered a visionary leader for future global disease pandemics, and the medical records kept during the 1918 pandemic remain crucial for informing current responses to biological outbreaks.
- Sterilization: In 1879, Dr. Charles Chamberland, influenced by Denis Papin’s pressure cooker and Louis Pasteur’s research, invented an early prototype of the modern-day autoclave. His work led to the development of the Chamberland Filter for removing microorganisms from water and the Chamberland Autoclave for destroying dangerous microorganisms by heating solutions above their boiling point.
- Technology: Key technological advancements included Wilhelm Conrad Rontgen’s accidental discovery of X-rays in 1895, which revolutionized the diagnosis of musculoskeletal disorders and injuries. Another significant innovator was Dr. Peter Safar, known as the “architect of Intensive Care”. In 1956, he developed the A–B–C technique (airway/breathing/circulation) for cardiopulmonary resuscitation (CPR), which gained worldwide acceptance. Safar collaborated with Norwegian toymaker Asmund Laerdal to create the realistic Resusci-Anne doll for CPR training, a prototype for modern emergency simulation. He also revolutionized pre-hospital care in the late 1950s by advocating for fully equipped ambulances staffed with emergency medical technicians.
- Education: The quality of medical education in the U.S. was inconsistent after a rapid increase in medical schools following the War of 1812. In 1910, Abraham Flexner presented research sponsored by the Carnegie Foundation, revealing significant issues such as a lack of formal tuition, prerequisite academic preparation, and mandatory written exams. Flexner proposed a four-year medical school curriculum and specific admission requirements, leading to the closure of many medical schools and a significant reform in medical education. This reform was followed by the development of the Medical College Admission Test (MCAT) in 1928, marking a major step in the quality journey for medicine.
- Pharmaceuticals: The article highlights the discovery of vaccines as a major advance in healthcare quality. Notable vaccine discoveries between 1881 and 1955 include Anthrax and Rabies by Louis Pasteur, Diphtheria by Emil von Behring and Shibasaburo Kitasato, Tetanus by Pierre Descombey, Polio by Jonas Salk, and Pertussis by Pearl Kendrick, Grace Eldering, and Margaret Pittman. Additionally, Sir Alexander Fleming discovered the “Wonder Drug” penicillin in 1928. Penicillin revolutionized medicine, as prior to its discovery, even minor injuries and common diseases could be fatal.
- Healthcare Financing: The 19th and 20th centuries saw the emergence of different healthcare payment models. In Germany, Chancellor Otto Von Bismarck designed a state-run medical insurance program in 1883, laying the foundation for Germany’s centrally administered, government-financed healthcare system. In England, William Beveridge’s 1942 report led to the establishment of the National Health Service (NHS) in 1948, providing free medical treatment for all. In the United States, healthcare financing developed differently, with Henry Kaiser, an industrialist, designing a prepaid program for his employees in the 1930s and 40s, which evolved into Kaiser Permanente, the largest HMO globally today. The article notes that while German and British models became universal coverage models in Europe, the U.S. system developed in a fragmented, employer-based manner.
- The Role of Industry and Mass Production: Outside of healthcare, deliberate quality improvement efforts also took root. In 1908, Henry Ford’s assembly lines employed efficient management systems, such as the “six-sigma lean method”, which reduced waste and increased productivity. These industrial techniques have since been adopted by healthcare for quality improvement.
Conclusion: The article concludes that Florence Nightingale’s contributions laid the groundwork for modern quality assessment, with her methods of measuring quality improvement, documenting results, and gaining support for interventions forming the foundation for today’s international benchmarks of excellence. The history of healthcare quality from 1860-1960 is presented as a series of pivotal, often disparate, events and innovations that collectively shaped the trajectory of healthcare quality improvement globally.
Reference: Sheingold, B. H., & Hahn, J. A. (2014). The history of healthcare quality: The first 100 years 1860–1960. International Journal of Africa Nursing Sciences, 1, 18–22. http://dx.doi.org/10.1016/j.ijans.2014.05.002
