Century Old QI Lessons

By  |  November 26, 2014 | 

Some days it seems like it would be easier to start from scratch. Maybe build your own hospital.

EA Codman

EA Codman

That’s what Ernest Codman decided to do.

Codman was born in Boston, graduating from Harvard Medical School in 1891. This was before the Flexner report fundamentally changed medical education in the US, and around the time medicine in America was starting to come into its own.

Codman was a passionate supporter of quality, for his patients, and the medical profession. He remains in the pantheon of great surgeons, though hidden behind many other giants in medicine. Various articles have been written about him over the years(by Berwick, Reverby, Donabedian, and a biography by Mallon), yet few know of his numerous accomplishments.

Here are three Codman breakthrough ideas and lessons learned.


Boston is the birthplace of anesthesia (unless you trained in Atlanta, like myself, and assign the ether discovery to Crawford Long). The origin of the word is attributed to the famous Boston intellect, Harvard Medical School Dean and Autocrat Oliver Wendell Holmes. The first recorded use of ether at Mass General Hospital (MGH) was by Morton in 1846. Another essential element of anesthesia history is a 3rd Boston gift: the ether chart.

In 1894, at MGH, the medical students EA Codman and Harvey Cushing (yes, the Harvey Cushing) were concerned about patients dying during surgery. The students decided to compete for a dinner by searching for ways to keep their patients safer. They devised the first version of the ether chart by keeping a running record of their patients’ vital signs every 5 minutes during surgery.

Anesthesia is one of the great healthcare safety stories. And Codman, as a medical student, was there at the onset. This set the stage for his search for quality in healthcare, even if it was to the detriment of his career.


“The common-sense notion that every hospital should follow every patient it treats long enough to determine whether or not the treatment has been successful and then to inquire, ‘If not, why not?’ with a view to preventing similar failures in the future.” –EA Codman

Codman asked his fellow surgeons to keep close records of their cases, to follow their patients over time. They were to keep end result cards yearly, and then would discuss what went well, and what did not. An honest, early version of morbidity and mortality.

As hospitalists, without an office to follow up on our patients, this seems like a “common sense notion.” Shouldn’t we be doing this already? In the burgeoning field of big data, this is a report I would want regularly: a detailed yearly update of patients I saw in the hospital, perhaps noting potentially preventable readmissions,  if any final diagnoses changed, new diagnoses that emerged, and then a strategy to learn from this information.

Codman was well ahead of his time. So far ahead, that we have yet to catch up. In 1915, his End Result Idea was too radical for the medical community, and he was kicked out of the Boston medical community. He eventually built his own hospital to put his ideas into practice.

His passion for this concept was his undoing. He still waits for us to figure out how to get it right, how to add the layers of transparency, accountability, and feedback to our hospital report cards.


In 1913, the American College of Surgeons (ACS) formed, with Codman as one of the founding members.

Here are the standards from 1917 the ACS asked for all the hospitals to achieve:

  • Each hospital should have a medical staff
  • Members of the medical staff are chosen based on graduation from medical school, competency and character
  • Regular staff meetings to review cases should be held
  • Medical records should be written and filed for all cases
  • Each hospital will with lab and radiology section

The first review of these standards for the almost 700 hospitals at the time found about 12% met the standards. The results were burned in the basement of a New York City hotel.

The ACS found its footing, and hospitals recognized the importance of some basic standards. By 1931, 50% of hospitals met the standards. The ACS became part of the group of societies that forms The Joint Commission (TJC) decades later.

TJC has an annual Codman award in his honor, and this past summer they also honored him at a dedication to his previously unmarked grave. Looking through the lens of history, Codman laid out the ideas that still inspire us today.

Bottom Line Messages

  1. As a medical student, Codman developed the ether chart. If you want to do quality improvement, then do quality improvement.
  2. The End Result Idea is waiting to be utilized, asking for transparency, accountability and learning from mistakes.
  3. Continue to fight for standardization, within the goals of quality improvement.
  4. And if all else fails, maybe you can build your own hospital.

CODMAN ACHIEVEMENTS: from Passaro E, Organ C. Bull Am Coll Surg 199 Jan;84(1):16-22

  • Develops the ether chart
  • First fluoroscopic study of the gut
  • Describes subacromial bursa
  • Describes fracture of carpal scaphoid
  • Management of perforation and obstructing duodenal ulcers
  • Publishes book THE SHOULDER
  • Starts first pediatric radiology department
  • Develops concept of end result idea
  • Helps develop the first hospital standards
  • Builds his own hospital
  • Starts registry of bone sarcoma: the first tumor registry


  1. Casey Quinlan (@MightyCasey) November 18, 2014 at 12:22 pm - Reply

    Jordan, your knowledge of medical history is always a treat. Love this, have shared it with my participatory medicine and patient-safety communities. Those who don’t study history are condemned to repeat it, aren’t they?

  2. Jordan November 26, 2014 at 12:24 am - Reply

    Thanks so much Casey for the kind comments. We do seem to repeat a lot of history. Some nice lessons from the past, may help us move forward more effectively and efficiently.

Leave A Comment

About the Author:

Jordan Messler
Jordan is a hospitalist at Morton Plant Hospitalists in Clearwater, Florida. He currently chairs SHM’s Quality and Patient Safety Committee. In addition, he’s been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control. He went to medical school at University of South Florida, in Tampa, and completed his residency at Emory University. He recognizes the challenges of working in a hospital that lines the intracostal waterways of a spring break mecca. Requests that if you want to be selected as a mentored site, you will have a similar location with palm trees and coastline nearby. He tries to find time to sit on the beach with his family to escape the hospital’s miasma. While there, he looks forward to reading about the history of hospitals/medicine, and how it relates to quality (Anti-UpToDate reading material). But inevitably will get a five year old dumping sand on him, and then has to explain why she is buried up to her neck.


Related Posts

By  | July 7, 2015 |  2
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them […]
By  | June 18, 2015 |  5
Life is short, the art is long. -Hippocrates Aphorism Our pivotal moments today are holding warm hands and discussing issues of survival and comfort. And yet, the journey into medicine began with cold fingers and deciding which tortuous tool to use next. The medical school told us, “We trust you, you are now on the […]
By  | January 29, 2015 |  0
Before going to sleep read for half an hour, and in the morning have a book open on your dressing table. -Osler What is on your nightstand? I’m not asking about the NEJM issue from 2013 that you still haven’t gotten to; or the gadgets glowing or dinging through the night; or the accumulating used […]