after World War II, however, when the concepts of modern quality improvement emerged, initially focusing not on health outcomes but on systems change in business and industry. The Revolution of Quality Improvement in Business and Industry Beginning in the mid 1920s, Walter A. Shewhart and W. Edwards Deming, both physicists, and Joseph M. Juran, an engineer, laid the groundwork for modern quality improvement. In their efforts to increase the efficiency of American industry, they concentrated on streamlining production processes, while minimizing the opportunity for human error, forging important quality improvement concepts like standardizing work processes, data-driven decision making, and commitment from workers and managers to improving work practices.6 These elements of systems change, first applied to business and industry, ultimately trickled down to the American health care system as awareness of its need for improvement grew.9-12 Florence 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. History of the Quality Improvement Movement 4 marchofdimes.com Toward Improving the Outcome of Pregnancy III History of the Quality Improvement Movement Systems Change Reaches American Medicine In 1951, the American College of Surgeons, the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association formed The Joint Commission on Accreditation of Hospitals as a not-for-profit organization to provide voluntary accreditation to hospitals. Early on, The Joint Commission used the minimum standards of ACS’s Hospital Standardization Program to evaluate hospitals. In time, however, The Joint Commission, which became The Joint Commission on Accreditation of Healthcare Organizations in 1987, adopted more rigorous standards, which reflected the structure-process-outcomes model that Avedis Donabedian presented in his 1966 article, Evaluating the Quality of Medical Care. Who provides care and where (structure); how care is provided (process); and the consequences of care (outcomes) are all needed to measure quality, Donabedian argued.13 By the mid-1990s, The Joint Commission introduced into the accreditation process the elements of system change derived from the work of Deming, Shewhart and Juran: the role of organizational leadership, datadriven decision making, measurement, statistical process control, a focus on process, and a commitment to continuous improvement. Process was especially important to quality management expert Philip Crosby, former vice president of corporate quality for International Telephone and Telegraph, who espoused the value of preventing errors altogether by doing things right the first time. Crosby’s “zero defects” approach to quality improvement set the stage for two other models that focused on eliminating waste: Toyota’s “lean” operations and Six Sigma.14 Toyota’s lean operations, introduced in the 1980s, standardized work processes to avoid wasting resources, time and money. Six Sigma, which Motorola developed in the late 1980s, also strives to improve quality during the process stage. It refers to a statistical measure of variation, but instead of using percentages, Six Sigma assesses “defects per million opportunities” and aims for fewer than 3.4 defective parts per million opportunities.15 The Role of NCQA in Improving Quality of Health Care In the late 1980s, corporate purchasers had fixed on a strategy of the accountable health plan to contain their health care costs. Led by many of the Fortune 500 companies that had adopted the principles of total quality management (e.g., Xerox, Ford, General Motors, Bank of America) or continuous quality improvement, they were seeking to enroll their employees in health plans that would measure their quality and continuously improve it. In 1988, the National Committee for Quality Assurance (NCQA) changed its governance to put health plans in the minority on the board, and developed a multistakeholder board, including these corporate purchasers, consumers and quality experts. NCQA worked with these corporate leaders and with health plan quality leaders to develop standards for what a true Health Maintenance Organization would be. NCQA’s accreditation standards were developed around many of Deming’s and Juran’s ideas, and the program was launched in 1991. At the same time, NCQA took on a project that had been developed by a number of health plans and purchasers to standardize quality measurement. In 1993, NCQA published its first Health Plan Report Card, using the Healthcare Effectiveness Data and Information Set (HEDIS). For the first time, it was possible to compare health plans on the effectiveness of care that their members received. HEDIS and NCQA accreditation were parallel projects for a number of years. In 1999, NCQA made HEDIS (including standardized patient experience results) an official part of its accreditation program, Toward Improving the Outcome of Pregnancy III marchofdimes.com 5 History of the Quality Improvement Movement and plans’ performance relative to each other now