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Assessing risk to improve outcomes is not a new principle. Formal assessment of patient care to improve outcomes dates back millennia. While it may be hard to establish an exact beginning, there are historical times and iconoclastic health-care providers who stand out as important contributors to the modern concepts of quality assessment and performance improvement. At least six individuals stand out as iconoclasts in the field of performance improvement in surgery (Table 7-1). From the practice-changing observational studies of medieval surgeons like Albucasis and Trotula to the twentieth century insistence on evidence-based studies and randomized controlled trials (RCTs) by Archie Cochrane, many individuals served as champions of performance improvement using the tools of their times. The six people outlined in Table 7-1 had exceptional effects on differentiating good from bad outcomes and on implementing process improvements that benefit our patients today. Each of these six shared a common life experience. At some time in their careers, they were outcasts among their peers. Their peers, and in some cases the public, chastised them for stating the obvious. Thankfully, they persisted despite these unpopular reactions. Reading the historical accounts of these six individuals reminds one that today’s public resistance to straight-forward observations is a long-standing perpetual obstacle that surgical leaders overcame.

Table 7-1:Shaping the Quality of Surgical Care Over Millennia

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