PAHS 423

PRINCIPLES OF HEALTHCARE
QUALITY ASSURANCE
STUDY GUIDE
Session 4 – History and evolution of healthcare quality

Lecturer: Nana Nimo Appiah-Agyekum (PhD), UGBS

Contact Information: nnappiah-agyekum@ug.edu.gh

College of Education
School of Continuing and Distance Education
2014/2015 – 2016/2017
 Session Overview
Knowing the past is an essential component of changing
our future. Consequently, this session takes you through
how quality and healthcare quality in particular has evolved
into what it is now over time.
At the end of the session, the student will be able to
• Explain the evolution of quality
• Describe how healthcare quality has evolved over the
years into what it is now
• Explain how healthcare quality can be improved based on
its evolutionary pathways
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 Session Outline
The key topics to be covered in the session are as follows:
• Topic One : Evolution of healthcare quality
• Topic Two : Evolutionary paths to healthcare quality
• Topic Three : Some key historical advancements in
healthcare quality

Slide 3
 Reading List
• Merry, M. D., & Crago, M. G. (2001). The past, present and future of
health care quality. Physician Executive, 27(5), 30-6.
http://www.tuvamerica.com/services/medical/articles/merry.pdf
• Sheingold, B. H., & Hahn, J. A. (2014). The history of healthcare quality:
The first 100 years 1860–1960. International Journal of Africa Nursing
Sciences, 1, 18-22.
http://www.sciencedirect.com/science/article/pii/S2214139114000043
• Dooley, K. (2000). The paradigms of quality: evolution and revolution in
the history of the discipline. Advances in the management of
organizational quality, 5(1), 1-28.
https://www.researchgate.net/profile/Kevin_Dooley/publication/2285
98156_The_Paradigms_of_Quality_Evolution_and_Revolution_in_the_
History_of_the_Discipline/links/0046353494134e5c5b000000.pdf
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Topic One

EVOLUTION OF HEALTHCARE
QUALITY
Slide 5
 Evolutionary paths to healthcare
quality
Historically, 3 paths to quality healthcare standards
exist
• The regulatory path leads to punishment and
blame.
• The learning science path splits, with one road
leading back to harsh regulations and the other to
the halls of academic medicine.
• And the management science path, while short,
will be the road to success in improving quality
Slide 6
 Butell et al (2007)

PAHS 423: lecture 2 Slide 7

UGBS, GBS9, nananimo0@gmail.com
Necessary factors for positive transition
between and among evolutionary paths
• Maintaining the best values of medicine’s learning
science tradition
• Understanding, creating and managing organizational
culture
• Developing new leadership concepts and practices
• Integrating management science with clinical care
and care system design
• Establishing innovative external review processes that
can genuinely help committed organizations achieve
their quality goals
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Topic Two

EVOLUTIONARY PATHS TO
HEALTHCARE QUALITY
Slide 9
 Regulation
• Begins and resides within medicine and other
professional practices which are taught and learned
as a craft - the product of a long textbook, classroom
and apprenticeship process.
• Quality is based almost solely on the skills of the
craftspeople and craft traditions are virtually blind to
systems issues central to Column 3’s management
science.
• Controlling quality therefore resided in guiding,
regulating, accreditation and punishing craftsmen
and their skills rather than systems
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 Learning science
• Quality revolved round lessons learnt from outstanding practices,
continuous assessments and trials to see how improvements and
reforms could be made to health issues and systems
• Learning experiences from peer review, assessments or discussions
of patient death or other adverse outcome for instance provides
insights to assess whether the outcome might have been
preventable.
• Models, theories, concepts and other principles were developed
which provided lessons that could be learnt to manage and
improve quality
• Non-compliance to standards developed based on lessons learnt to
guide and assess providers was punished through mandatory
recommendations, sanctions, financial penalties, and even
imprisonment.
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 Management science
• All other industries with the exception of healthcare was
improving continuously and providing increasingly good
service at a lower cost.
• Pioneering physicians, hospitals and other health care
organizations combined with quality experts from
manufacturing and service industries to launch an
ambitious experimental introduction of management
practices.
• This experiment was a definitive success, proving that
management science-based techniques could duplicate in
health care exactly what it had done in all other industries.
• With proof that process improvement can simultaneously
improve quality and lower cost, the continuous quality
improvement wave in health care was under way.
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 Topic Three

SOME KEY HISTORICAL ADVANCEMENTS IN

HEALTHCARE QUALITY

Slide 13
Florence Nightingale and quality improvement
documentation
• In 1854, Nightingale was able to reduce mortality rate from
42.7% to 2.2% among British troops fighting in Crimea
• Her specific improvements included increasing ventilation,
reducing overcrowding (spacing beds 3ft apart), removing
cavalry horses stabled in the hospital basement, flushing the
hospital sewers several times a day, and disinfecting the
latrines/drains with peat charcoal (Nightingale, 1863)
• Her meticulous records are key to present day statistical quality
measurement, and she was an innovator in the collection,
tabulation, interpretation, and graphical display of descriptive
statistics. She named her graphical data display a ‘‘Coxcomb’’
which is known today as a pie-chart (JCR, 1999).
Sanitary commissions and enforcing healthcare
quality through inspections
• The Sanitary Commission was founded as an alliance of
relief organizations in 1861 at the start of the American
civil war.
• Based on lessons learned from the Crimean War, it
aimed to promote clean and healthy conditions in the
Union Army camps and hospitals who were dying from
dysentery, typhoid and malaria.
• Sanitary Commission Agents patrolled Union Army
camps inspecting the living conditions and the
hospitals, organized diet kitchens, made bandages, and
conducted door to door ‘‘blanket raids’’ to prevent
soldiers from sleeping on the ground at night.
 Rupert Blue’s Quality tools for pandemics I
•Dr. Rupert Blue was the Surgeon General in the USA during
the influenza Pandemic of 1918 that killed about 50 million
people (1/5 of the world’s population) (USDHHS, 2013).
•During the pandemic, Dr. Blue’s main quality tools were
quarantine (including ships entering the country),
mandatory medical exams for all immigrants entering USA,
communication through weekly newsletters of information
on the latest outbreaks, and the results of influenza
research conducted at the Hygienic Laboratory.
•Also, the use of quarantine and masks while in public
formed the basis of the modern day management of SARS
outbreaks
 Rupert Blue’s Quality tools for pandemics II
• The enforcement of Dr. Blue’s healthcare quality plan was
done by the police and public transportation employees.
• Dr. Blue is viewed by many historians to represent the kind
of visionary quality leader needed in the event of global
disease pandemics of the future.
• The medical records kept during the 1918 influenza
pandemic continue to be some of the most researched
archival documents used by international scientists today.
• They serve to inform how we should respond to a similar
widespread outbreak of biological disease, and provide
data on the long term effects of the flu on pregnant
woman.
 Sample Question
• How has the historical advancements of healthcare
quality influenced how healthcare is practiced in Ghana?
• How have the factors that necessitated the evolution of
healthcare quality changed over time?

Slide 18
 References
• Joint Commission Resources (1999). Florence Nightingale:
measuring hospital care outcomes. Oak Brook, Illinois: Joint
Commission Resources
• Nightingale, F. (1863). Notes on hospitals (3rd ed.). London,
England: Longman, Greene, Longman, Roberts and Green
• United States Department of Health and Human Services. (2013).
Biographies: Rupert Blue.
http://1918.pandemicflu.gov/biographies/01.htm.

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