The Background and Evolution of Quality and Performance Improvement in Healthcare

The current healthcare system is the result of over a century of incremental quality and performance improvement measures. As Marjoua and Bozic said in Brief history of quality movement in US healthcare, “It began with an acknowledgment of the role of quality in healthcare, and gradually evolved to encompass the prioritization of quality improvement and the development of systems to monitor, quantify, and incentivize quality improvement in healthcare.” The history of quality and performance improvement can be broken down and studied in many different ways. However, we’ll look at the initial acknowledgment of the institutional developments that arose from those realizations.


Initial Acknowledgements of the Need for Performance Improvement


Pioneers like Florence Nightingale who realized both the inadequacy of the current quality of healthcare and saw ways to improve it paved the way for decades of performance improvement initiatives. There are countless medical trailblazers who saw problems with the current system and sought ways to change it, and they paved the way and set examples for those who would come after them. In response to acknowledgments of systematic inadequacies, institutions like the American Medical Association, the National Institutes of Health, the Institute of Medicine, and the National Center For Quality Assurance were born. First, however, let’s take a look at some of the individual accomplishments and contributions of early pioneers.


Helen Brooke Taussig (1898-1986)


Helen B. Taussig developed performance improvement measures in the fields of pediatric cardiology and palliative care.


Helen Brooke Taussig’s book Congenital Malformations of the Heart, which she published in 1947, helped establish the field of pediatric cardiology. She also contributed a body of work that helped to further progress in the areas of hospice and palliative care. Her work helped to address some of the issues of her time, such as helping physicians understand the differences in adult and pediatric cardiology and offering practical help for performance improvement. She later became an activist in political issues, as well, all centered around patient rights.


Zora Janzekovic (1918-2015)


Zora Janzekovic transformed the treatment of burn victims.


Before Janzekovic’s work, burn patients had to endure long and painful procedures during treatment, most of which did little to provide long-term healing and quality of life. However, Zora Janzekovic pioneered an entire field of medicine centered around the treatment and care of burn victims. Realizing that early excision and the immediate grafting of burn injuries were the keys to treatment success, Janzekovic saved countless lives and developed surgical procedures that are still used today to provide top-level care to burn victims. By acting on keen observations, she made a notable contribution to performance improvement in her field and also improved the lives of patients she would never meet.


Edwin Jenner (1749-1823)


Dr. Jenner made a keen observation that led to the groundbreaking discovery of the first vaccine.


Edwin Jenner was responsible for the creation of vaccines. The British surgeon and naturalist created the very first vaccine, which was for smallpox, in 1796. Once again, Jenner is an example of someone who made a keen observation, tested a theory, and developed a performance improvement strategy that drastically altered healthcare forever. He noticed that milkmaids who contracted cowpox never contracted smallpox. That made him consider the option that perhaps having a less-destructive form of the illness meant you would be immune from contracting a worse form. He inoculated his own son with cowpox, and even after the boy was repeatedly exposed to smallpox material, he never contracted it. This discovery paved the way for disease prevention for years to come.  


Institutional Development as a Response to Performance Improvement Needs


In addition to these (and countless more) individual contributions, four key institutions were developed, as well, in response to the need for performance improvement measures. Many other institutions were also created, especially those dedicated to specific areas of medical practice. However, these four generally helped most in the development of systems and procedures that enhanced quality and performance improvements.


American Medical Association (AMA)


The AMA is dedicated to performance improvement measures across all of healthcare.


The American Medical Association (AMA) was created in 1845. It began as a resolution to the New York Medical Association. That resolution was put forth by Dr. Nathan S. David. He saw a need for a national association committed to the same end goals as the state association was. The AMA was committed to four main objectives, to which it still remains true today: scientific advancement; standards for medical education; a program dedicated to medical ethics; and improved public health. In 1905, the AMA established a council to set standards for drug manufacturing and advertising.  In 1910, the Flexner Report, Medical Education in the United States and Canada, established new and stricter standards for medical schools. Later, in 1927, the AMA’s Council on Medical Education and Hospitals published its first list of hospitals that were approved for residency training, and in 2008 the association committed to being more demographically inclusive in an effort to improve healthcare equity. It continues to make strides and set standards that consistently improve the overall performance and quality of healthcare as a whole.


National Institutes of Health


The NIH is dedicated to furthering performance improvement through research and development strategies and practices.


The National Institutes of Health (NIH) began as a one-room laboratory operating in cooperation with the Marine Hospital Service (MHS) to prevent epidemics by examining passengers arriving in merchant ports. In 1902, the NIH began studying spotted fever in the Rocky Mountains, specifically in Montana. By 1920, the Rocky Mountain Spotted Fever Laboratory was established in a former Hamilton, MT school building. It became a registered US Public Health Service (formerly MHS) field station. In 1948, the Rocky Mountain Laboratory and the Biological Control Laboratory became two of the four major components making up the National Microbiological Institute. These rapid developments are a trademark of the NIH. They concurrently undertook, and continue to undertake, development projects, research initiatives, and performance improvement tasks in the areas of Alzheimer’s, cancer, dental health, pediatrics, mental health, and a host of other healthcare sub-fields. The NIH is still one of the foremost organizations as it relates to healthcare development, medical research, and disease mitigation.


Institute of Medicine


The Institute of Medicine takes a multidisciplinary approach to quality and performance improvement in the healthcare industry.


The Institute of Medicine (IOM) was established in 1970. In 2015, the National Academies of Science, Engineering, and Medicine published a press release stating that the IOM would become the National Academy of Medicine (NAM). However, the new incorporation doesn’t detract from the purpose of the organization. In the release, the National Academy of Sciences President Ralph J. Cicerone said this new incorporation would “better align us to take a more integrated, multidisciplinary approach to our work, reflecting how science is bet done today.” In essence, that has always been the goal of the IOM. For decades, the Institute has combined best practices in medicine, engineering, technology, and other sciences to keep up with changing demands and create successful and effective performance improvement measures throughout healthcare. This interdisciplinary approach has helped them to create some of the most innovative solutions in the industry.


National Committee For Quality Assurance (NCQA)


The National Committee For Quality Assurance creates standards and report cards that help maintain and define quality and performance standards for healthcare.


The National Committee For Quality Assurance (NCQA) exists to further performance improvement efforts by providing resources and standards, assisting health care providers and practitioners, working to improve health plans, and providing data and information technology (IT). Perhaps best known for their report cards, education and training, and implementation of HEDIS measures and related technical resources, the NCQA has played a pivotal role in quality and performance improvement. Their report cards provided actionable steps for many facilities and organizations that went on to create transformational change in medicine, and their grading standards are still used today to ensure quality.




We’ve made a lot of changes as an industry, but now, a new wave of modern challenges demands us to look for novel performance improvement measures in data analytics, AI, machine learning, and healthcare IT in order to successfully address the need for modern solutions to quality care. Healthcare data analytics and big data are already paving the way for modern researchers and developers to answer the call for comprehensive and responsive solutions that lead to better decision-making, better care, and better overall quality in the system at large.