Chapter 7

### Historical—Hunter, Nightingale, Codman, and Cochrane

It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals…is very much higher than…the mortality of the same class of diseases among patients treated out of hospital…

Florence Nightingale, 1863

Surgeons often assume that performance improvement is a new concept arising from the complexities of modern medicine and surgery. Assessing risk to improve outcomes is not a new principle. The formal assessment of patient care had its beginnings in the mid-1800s.One of the earliest advocates of analyzing outcome data was Florence Nightingale, who was troubled by observations that hospitalized patients died at higher rates than those treated out of hospital.1 She also noted a vast difference in mortality rates among different English hospitals, with London hospitals having as high as a 90% mortality rate, whereas smaller rural hospitals had a much lower mortality rate (12 to15%).Although England tracked hospital mortality rates since the 1600s, the analysis of these rates was in its infancy. Nightingale made the important observation that raw mortality rates were not an accurate reflection of outcome, because some patients were sicker when they presented to the hospital and, therefore, would be expected to have a higher mortality. Nightingale translated these observations into a highly successful improvement plan by suggesting simple measures such as better sanitation, less crowding, and location of hospitals distant from crowded urban areas. Her observations and action plans likely represent the beginning of risk adjustment to implement performance improvement.

Earlier contributions to performance improvement came from John Hunter in the 1700s. Hunter was relatively uneducated by the standards of the time but he had two qualities that allowed him to become the pre-eminent surgeon of the time and the father of modern surgery.2 He had great technical skill and a belief that disease was caused by anatomic abnormalities. More importantly, he was unwilling to accept hypothetical abstract explanations of illness like “humors” or “spirits.” He required that he verified causes of illness himself and that he could explain them on the basis of anatomy. For example, treatment of venereal disease was an important part of a physician's practice in the mid-1700s.Hunter was outspoken about the failure of the majority of medications claiming to cure gonorrhea. He said that “gonorrhea could be cured by the most ignorant, because gonorrhea mostly cures itself.” He even performed an ingenious test by treating some of his patients with pills made of bread. He recorded the results and almost all of the patients had resolution of gonorrhea. This was one of the first trials documenting the placebo effect. John Hunter's friends and patients included Benjamin Franklin, Edward Jenner, Lord Byron, Casanova, and Adam Smith. His list of enemies was probably equally ...

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