recently from 12.7 percent (2007)1 to 12.3 percent (2008).2 But we must continue to seek solutions if these small gains are to be preserved and accelerated. And solutions may be at hand. Most recently, two Institute of Medicine (IOM) reports — To Err Is Human: Building a Safer Health Care System (1999) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001) — revealed the high rate of preventable errors in hospitals and the extreme complexity of systems that underlie most of those errors. As a result, there has been growing interest in the perinatal community in applying quality improvement strategies to prevent errors and to reduce the rate of prematurity. Based on a subsequent IOM report, Preterm Birth: Causes, Consequences, and Prevention, we now know that preterm birth costs our nation $26 billion annually in health and medical costs.3 Preventing preterm birth, through quality improvement approaches, offers an unprecedented opportunity to both bend the cost curve and to improve the outcome of pregnancy. The March of Dimes is hopeful that this third volume, TIOP III: Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives, will drive the implementation of model programs and quality improvement initiatives and will increase transparency and accountability for consumers — all of which can support improved pregnancy outcomes. Chapter 1: History of the Quality Improvement Movement Early Effects to Improve Clinical Care and Medical Education The evolution of quality improvement has been a steady response to the need to correct errors. Consider Florence Nightingale, a public health pioneer who addressed the link between paltry hospital sanitation and the high — 60 percent — fatality rate among wounded soldiers during the Crimean War of 1854. Germ theory was gaining traction in Europe and pointing to the link between high morbidity and mortality rates and the lack of basic sanitation and hygiene standards. Nightingale, while serving as a nurse at the Barrack Hospital in Istanbul, developed practices — hand washing, sanitizing surgical tools, regularly changing bed linens and making sure all wards were clean — that are standard in hospitals today. She also promoted good nutrition and fresh air. By the time this forerunner of evidence-based medicine left Barrack Hospital, mortality had plummeted to 1 percent.1,2 Mark R. Chassin and Margaret E. O’Kane Toward Improving the Outcome of Pregnancy III marchofdimes.com 3 Medical education underwent dramatic transformation after the publication of Flexner’s report. Many schools closed, some consolidated, and all tightened their entrance requirements. Length of study and training increased and incorporated biomedical studies in biology, chemistry and physics with strict, supervised clinical training.4 While just 50 percent of medical school graduates moved on to hospital training in 1904, an estimated 75 to 80 percent were taking internships by 1912.3 As Flexner’s report revolutionized the medical education system, Ernest Codman, a surgeon from Harvard Medical School and Massachusetts General Hospital, applied his “End Result System of Hospitalization Standardization Program,” a three-step approach to quality assurance, to improving hospital care. Codman’s system used quality measures to determine if problems stemmed from patients, the health care system or clinicians; quantified the lack of quality; and, remedied problems to prevent them from happening again.5 In 1917, the American College of Surgeons (ACS) adopted his “End Result System” for its Hospitalization Standardization Program, which set minimum standards for hospital care. These standards required that, among other things: all hospital physicians are well-trained, competent and licensed; staff meetings and clinical reviews occur regularly; and, that medical histories, physical exams and laboratory tests are recorded.6 In 1918, the ACS began using its newly established minimum standards to inspect hospitals. Of 692 hospitals, only 89 met the minimum standards. However, by 1950, the Hospitalization Standardization Program approved more than 3,200 hospitals.7 Improvements to Maternal Child Health Trigger Other Efforts While much concern about health care quality in the early 20th century revolved around hospitals, America’s high maternal and infant mortality rates, longtime indicators of quality, were also claiming attention. In 1921, Congress passed the SheppardTowner Act, which granted states funds to improve access to maternal and child health services. In 1935, Congress passed Title V of the Social Security Act, to equip and finance pediatric and primary care services for hospitals in underserved areas. The Emergency Maternity and Infant Care program followed, financing care for 1.5 million women and infants of United States soldiers during World War II. And, in 1946 came the Hill-Burton Act, which awarded grants to states to build hospitals.8 Efforts to provide women, children and the underserved with more and better care led to the creation of numerous programs, including Medicare and Medicaid. By the mid-1900s, improving the quality of health and hospital care was an idea with a century of effort behind it. It was