The article, “Evaluation of healthcare quality: a tale of three giants”, highlights that while the concept of quality of care has ancient roots, dating back to King Hammurabi’s Code around 1700 BC, Ernest Amory Codman, Avedis Donabedian, and Shukri Khuri are specifically credited with laying the groundwork for its modern evaluation and measurement in surgery. Historically, attempts to define quality, such as Hammurabi’s Code, prescribed both rewards for successful treatment and punishment for adverse outcomes, like cutting off a physician’s hand for a patient’s death during surgery. This historical context illustrates a persistent social theme of blaming physicians for less-than-desired outcomes, often overlooking the inherent risks of a patient’s health state, disease severity, or treatment limitations, which consequently weakened incentives and tools for evaluating healthcare effectiveness.
The Institute of Medicine (IOM) defines quality of care as “the degree to which health services for individuals and population increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. Medicine, described as a “soft science,” faces challenges in evaluation due to genetic and developmental differences among individuals, and subjectivity from both physicians and patients. Despite this, there is a strong drive to develop reliable tools for improving both the quality and economy of healthcare, a focus that became particularly prominent in the 20th century.
Here are the specific, detailed contributions of the three “giants”:
- Ernest Amory Codman (1869–1940)
- Codman, a Harvard Medical School graduate, was a figure of independent and stubborn creative genius. He was deeply involved in surgical care at Massachusetts General Hospital (MGH), where in 1908 he performed the first recorded successful operation for an acutely perforated duodenal ulcer. He also became a foremost authority on shoulder anatomy and function, publishing a still-authoritative volume titled “The Shoulder”.
- In 1900, he conceived the “End Result Idea,” a revolutionary vision that each hospital should analyze the results of treatment for every patient and study long-term outcomes to improve its treatment methods. He developed a templated system using 3×5 cards for data collection, including patient identification, diagnosis, treatment, results, and long-term follow-up.
- Using this system, he tabulated “end results” for approximately 600 cases of upper abdominal surgery over a decade (1900-1910), classifying them by diagnosis and individual surgeon. The convincing poor results led to a system of case assignments allowing individual surgeons to develop expertise in specific diseases or problems, which they would then disseminate to the rest of the staff.
- Codman introduced long-term follow-up for fracture treatment, evaluating anatomical, functional, and economic results on a 1-to-4 scale, a system still in use today.
- His efforts stimulated the establishment of weekly surgical morbidity and mortality conferences at MGH. In these conferences, all surgical cases are reviewed, and complications are adjudicated based on whether they resulted from errors in judgment (patient selection, indications for surgery, procedure choice), errors in technique, errors in management (pre- and postoperative care), or the patient’s disease itself. This tradition became widespread in the United States.
- Despite his groundbreaking work, Codman often faced scorn and social disapprobation. He famously protested against seniority-based promotion by resigning from MGH in 1914, then immediately reapplying as chief of surgery based on his superior results, a request that was ignored.
- He continued to enrage contemporaries by insisting that surgical quality be judged by patient outcomes, leading to abrasive criticisms. At a 1915 meeting on hospital efficiency, Codman unveiled a cartoon satirizing Boston’s academic physicians and hospitals as an ostrich with its head in the sand, symbolizing their failure to assess the value of medical services despite high fees. This presentation caused an uproar, leading to widespread media comment and a period of near-total social ostracism for Codman.
- Undaunted, he opened a private hospital in his own home to demonstrate his theories on efficiency based on scientific knowledge and integrity. He also initiated the Registry for Bone Sarcoma, which continues today under the American College of Surgeons.
- In a remarkable act of humanitarianism, following the 1917 Halifax explosion, Codman packed up his hospital and staff (along with his “End-Result cards”) and traveled to Halifax to care for the wounded and direct rescue efforts.
- Codman played a crucial role in the standardization of hospitals. He convinced Edward Martin, a founder of the American College of Surgeons, about the importance of quality surveillance. In 1912, Codman was appointed Chair of the Committee for the Standardization of Hospitals of the newly founded American College of Surgeons. This committee ultimately evolved into the Joint Commission on the Accreditation of Hospitals, the modern iteration of Codman’s original committee.
- His contributions were later recognized with the Joint Commission creating the Codman Award in 1996.
- Avedis Donabedian (1919–2000)
- Donabedian, though not a surgeon, was a central figure in defining medical care quality in the 20th century. Born in Beirut, Lebanon, he earned his medical degree from the American University of Beirut. His experience managing the University Health Service made him realize his need for administration knowledge, leading him to a scholarship at Harvard and a Master of Public Health degree in 1955.
- As the Nathan Sinai Distinguished Professor of Public Health at the University of Michigan, Donabedian studied and taught the principles of quality measurement in healthcare, defining it by three key components: structure, process, and outcomes.
- Structure: Conceived as the environment in which healthcare services are provided.
- Process: Described as the steps involved in the provision of medical services.
- Outcomes: Measured by various criteria according to the study in progress.
- Donabedian’s framework of structure–process–outcome provided the essential basis for the modern engineering design of surgical care delivery and allowed for the systematic quantification of the quality of medical care.
- He was deeply interested in the social structures for healthcare provision, its cost, and the attitudes of healthcare personnel and the public, recognizing the ambiguities posed by cost, public expectations, and resource limitations.
- His concepts and teachings had a profound influence on social attitudes and public policies related to healthcare in the United States.
- Donabedian was recognized by the Joint Commission in 1997 as the first recipient of the Ernest Amory Codman Award in the Individual Category. He also received the Sedgwick Award from the American Public Health Association, which also established the Annual Avedis Donabedian Health Care Quality Award.
- Shukri F. Khuri (1943–2008)
- Khuri, a cardiac surgeon and a prominent statistician’s son, was the third meteoric figure in healthcare quality. He completed his medical degree at the American University of Beirut and his cardiac surgery training at Johns Hopkins and the Mayo Clinic.
- Recruited to Harvard and the Boston Veterans Affairs (VA) Hospital, Khuri led dynamic clinical and research programs in perfusion and tissue preservation, transforming the Boston VA into a “Center of Excellence” in Cardiac Surgery.
- Khuri possessed scholarly brilliance, strong communication and leadership qualities, and a natural aptitude for quantification, making him adept at leveraging the power of computers.
- In 1986, a US Congress mandate requiring the Department of Veterans Affairs to compare its risk-adjusted surgical outcomes with those in the private sector prompted a VA team, led by Dr. Khuri, to develop the National VA Surgical Risk Study (NVSRS) in 1991.
- This program, which evolved into the National Surgical Quality Improvement Program (NSQIP), developed in tandem with the VA’s electronic health record system, VistA, making extensive use of its vast information reservoir, which now contains over 1.4 million extracted cases.
- One of Khuri’s and his colleagues’ most important contributions was the finding that surgical outcomes depend not only on the surgical team and individual physician but also heavily on the patient’s preoperative risk factors. He developed a quantifiable way to adjust postoperative outcomes based on patients’ preoperative variables and to improve outcomes by enhancing patients’ preoperative risk status.
- He developed the observed-to-expected (O/E) ratio in mortality and morbidity, which provided a standard and quantifiable method for hospitals to fairly compare themselves, irrespective of the patient’s condition at intake.
- For 14 years, Khuri directed NSQIP, which is now recognized as the model for continuous improvement in surgery. It is the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for measuring and enhancing the quality of surgical care.
- Since NSQIP’s inception, the VA System has seen significant drops in 30-day postoperative mortality (47%) and morbidity (43%).
- Khuri was awarded the Frank Brown Berry Prize in Federal Medicine in 1998. Two days after his death in 2008, the Joint Commission announced he was the twelfth recipient of the Ernest Amory Codman Award in the Individual Category.
Despite not directly collaborating, these “giants” built upon their predecessors’ work and shared common traits such as tremendous determination in the face of challenges and a deep enthusiasm for improving care. Their collective vision—focused on coordinated expert teamwork as the key to excellence in medical care and the systematic, objective measurement of healthcare quality—continues to shape health policy for the century to come. Their work implicitly challenges King Hammurabi’s ancient premise that blame and punishment are effective incentives for healthcare improvement.
Reference: Rodkey, G. V., & Itani, K. M. F. (2009). Evaluation of healthcare quality: a tale of three giants. The American Journal of Surgery, 198(5A), S4-S
