The article, “A Brief History of Quality Improvement in Health Care and Spinal Surgery”, by Kevin Hines, Nikolaos Mouchtouris, John J. Knightly, and James Harrop, offers a detailed account of how quality improvement efforts have evolved within the United States healthcare system, with a particular emphasis on their impact on spinal surgery. While medical and technological advancements are continuously shaping healthcare, the authors highlight the ongoing challenge of translating these into substantial improvements in overall healthcare quality outcomes in the United States.
The journey of improving patient care, a principle since the time of Hippocrates, has seen significant innovations over the past century. These advancements are crucial for understanding the future directions of quality improvement, especially in complex fields like spinal surgery.
Here’s a more detailed look at the key figures and organizations that have shaped this history:
- Abraham Flexner (Early 20th Century Contributor):
- He initiated the United States’ quality improvement efforts through a retrospective analysis and review of the healthcare system.
- His findings and recommendations were published in his 1910 Report to the Carnegie Foundation.
- The report criticized the poor organization of major hospitals and medical schools nationwide.
- Flexner aimed to enhance physician training by advocating for improved scientific methods and strengthening the validity of medical licensure.
- His report significantly restructured medical education in the United States, leading to the closure or merging of over half the medical schools.
- Ernest Codman (Pioneer of Patient Outcomes):
- An orthopedic surgeon, Codman championed quality improvement by utilizing patient registries and serial patient follow-up.
- He developed a systematic protocol for tracking long-term patient progression and “end patient results”.
- Codman believed that all patient outcomes should be tracked and made public, allowing patients to make informed choices about physicians and hospitals.
- His primary emphasis was on identifying effective versus ineffective healthcare treatments.
- Codman’s “end-result system” was a direct inspiration for Dr. Franklin Martin, who envisioned these principles assisting in surgeon and hospital standardization to improve patient care.
- The American College of Surgeons (ACS) and Hospital Standardization Program:
- Inspired by Codman, Dr. Franklin Martin largely proposed and catalyzed the founding of the American College of Surgeons in 1913.
- Initially, the ACS rejected 60% of fellowship applications in its first three years due to the inability to determine clinical competency from presented case records.
- As the ACS’s influence grew, a significant donation funded a hospital standardization program.
- In 1917, over 300 fellows and hospital administrators met to establish “minimum standards” required for hospitals nationwide and an accreditation process.
- These standards included five main objectives:
- Organize hospital medical staff.
- Ensure employment of only well-qualified and licensed physicians.
- Ensure regular staff and clinical performance review.
- Maintain thorough and organized medical records.
- Establish facilities such as clinical laboratories and radiology departments.
- When the Hospital Standardization Program reviewed 692 hospitals with 100 beds or more, only 89 met these minimum standards.
- This report highlighted the continuous need for quality improvement in the U.S. hospital system, and the “minimum standard” was officially adopted, becoming paramount in instituting organized quality improvement.
- The Joint Commission on Accreditation of Hospitals (JCAH):
- As healthcare grew in complexity and the scope of the Hospital Standardization Program expanded beyond surgery, the ACS alone could not sustain it.
- In 1952, the American College of Surgeons, American College of Physicians, American Hospital Association, and American Medical Association (briefly joined by the Canadian Medical Association) formed the Joint Commission on Accreditation of Hospitals.
- This independent, nonprofit organization began offering accreditation in 1953, upholding the values championed by the ACS.
- The Joint Commission expanded the program by hiring surveyors and conducting careful interviews and observations of medical staff and patient care issues.
- However, by expanding, the Joint Commission found that the standards were no longer sufficiently pushing hospitals for higher levels of quality.
- Avedis Donabedian (Founder of the Contemporary Quality Movement):
- Considered one of the founders of the contemporary health care quality movement.
- He published his influential paper, “Evaluating the Quality of Medical Care,” in July 1966, which became one of the most frequently cited public health pieces.
- Donabedian described seven pillars of quality in medicine:
- Efficacy
- Efficiency
- Optimality
- Acceptability
- Legitimacy
- Equity
- Cost
- To measure these goals, he introduced three types of metrics for evaluating quality in health care: structure, process, and outcome.
- Structure: Includes provider credentialing, adequacy of facilities, and administrative systems.
- Process: Observes the components of care delivered, their appropriateness, and competency of delivery; Donabedian noted that problems often lie in the process, not the individual.
- Outcome: Involves evaluation of recovery, restoration of function, and survival, necessary to determine effective interventions.
- He emphasized the need for clear presentation of these metrics (e.g., dashboards, scorecards) and broad quality measurements, laying the framework for patient individualized outcomes and value-based care.
- The Institute of Medicine (IOM) / National Academy of Medicine (NAM):
- Founded in 1970 by the National Academy of Sciences to advise the government on social, economic, and political aspects of healthcare.
- Its members include diverse professionals, from health disciplines to economists, sociologists, engineers, and business representatives.
- The IOM (now the National Academy of Medicine) produces roughly 50 well-vetted reports in medicine each year.
- Key publications include:
- “America’s Health in Transition: Protecting and Improving Quality” (1994): Asserted that healthcare quality improves outcomes and aligns with current knowledge, outlining obstacles like unnecessary/inappropriate care, underuse of effective care, and personnel shortcomings.
- “To Err Is Human” (1999): This report brought public attention to quality improvement, stating that nearly 100,000 preventable deaths per year occur due to medical errors. It highlighted the need for improved medical electronic information systems and better reporting of medical errors without liability for healthcare workers.
- “Crossing the Quality Chasm” (2001): Demonstrated discrepancies in healthcare delivery regardless of patient demographics or location. It proposed specific aims as drivers of healthcare change: safety, efficacy, patient-centered care, timeliness, efficiency, and equity.
- Further IOM efforts include redesigning primary care, restructuring insurance, educational reform, establishing core competencies, fostering training environments, and advocating for electronic health record systems with national standards. They also addressed common and costly medication errors in “Preventing Medication Errors”.
- The IOM’s quality improvement initiative consists of three phases, outlining the gap between current and ideal healthcare delivery and proposing mechanisms for transformation.
- Quality Improvement in Spinal Surgery:
- The quality improvement movement is expected to define the future trajectory of major specialties like spine surgery.
- Concepts such as outcome-based care, standardization, and resource efficiency will guide future policy, as health systems shift towards sustainable, value-based care models.
- Spinal surgery deals with a highly heterogeneous patient population with varied outcomes, leading to unexplained variation, waste, and high costs. Traditional prospective trials often lack generalizability due to rigid inclusion/exclusion criteria, making high-level evidence costly and difficult to apply.
- To address these deficiencies and the yet-undefined cost, efficacy, safety, and patient-centered outcomes, spine registries have gained popularity.
- Registries, building on Ernest Codman’s “end result theory,” represent a scalable, cost-effective alternative to randomized clinical control trials for evaluating outcomes in a more generalizable context.
- The National Spinal Cord Injury Database (NSCID), established in 1973, was the first major registry. It spurred advancements in spinal cord injury care by collecting prospective data on patient demographics, pathology, procedures, complications, implants, and patient-reported outcomes.
- Many other major registries have since been established, covering various pathologies, including the Swedish Spine Registry, Spine Tango, and QOD (Quality Outcomes Database).
- While spinal surgery generally has low morbidity and high sustained treatment effects, registries reveal significant heterogeneity and variation in treatments and individual responses.
- Despite variations in registry design and data, understanding these differences allows physicians to identify registries that best suit their patient population for clinical decision-making.
- These registries are crucial for improving quality care by identifying which patient cohorts will or will not benefit from a particular surgery.
- Data from registries like QOD can enable surgeons to create personalized predictive calculators for individual patient responses to therapy.
- As clinical registry databases and their information technology platforms improve, their predictive modeling capabilities and comparative power will continue to accumulate and drive quality improvement in medicine forward, providing invaluable data on comparative efficacy of treatments.
- These tools will allow treatment paradigms to be altered, leading to more efficacious, cost-effective, safe, and patient-centered spinal care.
The article concludes that understanding this extensive history of quality improvement is vital for spine surgeons as the field seeks to enhance outcomes for complex spinal patients, emphasizing that value-based and outcome-driven policy is increasingly important in every medical field, including spinal surgery.
Reference: Hines, K., Mouchtouris, N., Knightly, J. J., & Harrop, J. (2020). A brief history of quality improvement in health care and spinal surgery. Global Spine Journal, 10(1S), 5S-9S. https://doi.org/10.1177/2192568219853529