Doctors under the microscope: the birth of medical audit

Abstract

In 1989 a UK government White Paper introduced medical audit as a comprehensive and statutory system of assessment and improvement in quality of care in hospitals. A considerable body of research has described the evolution of medical audit in terms of a struggle between doctors and National Health Service managers over control of quality assurance. In this paper we examine the emergence of medical audit from 1910 to the early 1950s, with a particular focus on the pioneering work of the American surgeons Codman, MacEachern and Ponton. It is contended that medical professionals initially created medical audit in order to articulate a suitable methodology for assessing individual and organisational performance. Rather than a means of protecting the medical profession from public scrutiny, medical auditing was conceived and operationalised as a managerial tool for fostering the active engagement of senior hospital managers and discharging public accountability. These early debates reveal how accounting was implicated in the development of a system for monitoring and improving the work of medical professionals, advancing the quality of hospital care, and was advocated in ways, which included rather than excluded managers.

Keywords:

• medical audit
• professional accounting
• quality of care
• end results

Acknowledgements

The authors wish to thank the two anonymous reviewers for their insightful and helpful comments.

Notes

The websites http://trove.nla.gov.au/ and http://www.hathitrust.org/ were particularly useful.

In Scotland it was to be a Hospital and Community Health Medical Audit Advisory Committee in each Health Board area, and in England a District Medical Audit Advisory Committee in each district.

In other contexts, notably Sweden, medical professionals regarded the public disclosure of quality data as potentially advantageous (Levay and Waks 2009).

Codman alienated the members of the Suffolk (Massachusetts) District Surgical Society when, during a meeting held at the Boston Medical Society in 1915, he unveiled a cartoon that showed an ostrich burying his head under the sand and kicking up golden eggs (Wrege 1983). The ostrich represented the surgeons and hospital administrators who did not want to study their own results but were happy to lay golden eggs. The local press (Boston Post and Boston Daily Globe) reported the story ‘(Cartoon raises surgeon's ire: Dr Codman stirs up medical society’) and the Suffolk Medical Society asked Codman to resign from its Surgical Section, which he did.

The other members of the Committee were as follows. J.G. Clarke MD (no biographical data available); W.J. Mayo, MD, FACS, a highly respected physician and surgeon who studied at the University of Michigan and one of the founders of the Mayo Clinic and President of the ACS from 1917 to 1920 (http://www.facs.org/archives/presidentslist.html). Allen B. Kanavel, an internationally renowned surgeon, who graduated from Northwestern University Medical School, where he subsequently became Head of the Surgical department. He was editor of Surgery, Gynecology and Obstetrics, one of the organisers of the ACS, on which he served on the Board of Regents and was also as its President from 1931 to 1932 (Phemister 1938). W.W. Chipman, MD, CM, FRCS, Professor of Gynaecology and Obstetrics at McGill University, Montreal who was one of the founding members of the ACS, studied at Edinburgh University and worked at Edinburgh Royal Infirmary, Bolton Infirmary and the Royal Victoria Hospital, Canada. He was President of the ACS from 1926 to 1927 (http://www.facs.org/archives/presidentslist.html).

After his resignation Codman served in the Army during the First World War. He struggled to rebuild his surgical practice on his return from military service. He died in 1940 and was buried in an unmarked grave as he thought that the cost of a headstone would have been a financial burden for his wife.

The book was revised and updated by MacEachern and republished in 1953, leaving Ponton as the sole author. Thus, in this paper, when referring to this publication we cite Ponton (1939).

The Standard Nomenclature of Diseases and Operations was initially published in 1928 by the New York Medical Association before responsibility for its maintenance and revision was transferred to the American Medical Association in 1937. It was the standard reference work for diagnosis.

The following items were deemed to be illustrative of quality of care and therefore analysed and reported on by the audit: end results of the care provided to patients (classified as recovered, not recovered, improved, not improved, not treated, in for diagnosis only, died); death rate expressed as a ratio of all deaths to total discharges and deaths in a given period, analysed for the hospital as a whole, by the services provided and by physicians; anaesthesia death rate, i.e. deaths caused by anaesthetic agents; postoperative death rate, i.e. death connected with an operation; maternal death rate, i.e. the ratio of maternal death to obstetrical discharges; infant death rate, i.e. the ratio of death of infants newly born in the hospital to viable deaths; autopsy rate, considered to provide a proxy measure of scientific interest of medical staff; consultations, i.e. rate of formal consultations (those held at the bedside, for which the findings are recorded and there is evidence of study of the patient history and of physical examination of the patient); complications, as they are considered to be potential indication of weaknesses in the service; infection rate, useful for assessing the competence of surgical and obstetrical services; unnecessary surgery; average length of stay; percentage of occupancy (80% was deemed the limit for efficient bedside care).

The following authors/publications a represent a sample of works that documented and discussed the implementation of the model of medical audit devised by Ponton and MacEachern, stressing the benefits on the improved quality of care and on the engagement of management/governing body in the activities of the hospitals: Editorial (1950), Weinerman (1951), Agnew (1951), Herman (1952), Sereda and Hanson (1952), Smith (1953), Mortund (1953), Krause (1953), Sister Justina (1954), Berry (1954), Hawley (1954), Myers and Stephenson (1954), Letourneau (1954), Johnson (1955a, 1955b), Harm (1955), Johnson (1956), Sewall and Davidson (1956), Eisele (1956), Myers (1957), Butler and Quinlan (1958), Munter and Berke (1958), Gogan (1959), Plewes (1959), Editorial Comments (1959), and Sewall and Berger (1959).

Lembcke graduated in medicine at the University of Rochester, where he trained in Paediatrics. In 1935, he joined the New York State Department of Health. He subsequently completed a Master of Public Health at Johns Hopkins School of Hygiene and Public Health. He worked for a few years for the Rochester State Health District and in 1944 became the director of the newly created New York State Legislative Commission on Medical Care and later became Associate Director of the Council of Rochester Regional Hospitals. In 1951, he was appointed Associate Professor of Public Health Administration at Johns Hopkins School of Hygiene and Public Health with the remit to direct the graduate programme in hospital administration, and was an Associate in the administration of the hospital. Whilst working at Johns Hopkins he published his seminal work on medical audit, and studied hospital administration in Sweden and Israel funded by the Rockefeller Foundation and the World Health Organisation. In 1957, he became Professor of Preventive Medicine in the Medical School and Professor of Public Health at the University of California in Los Angeles (Silver 1990).

Avedis Donabedian was a Nathan Sinai Distinguished Professor of Public Health at the University of Michigan.

By regulative institutions we mean ‘explicit regulative processes: rule-setting, monitoring, and sanctioning activities’ (Scott 1995, 35), and by cognitive rules we mean ‘rules that specify what types of actors are allowed to exist … and what procedures they can follow’ (Ruef and Scott 1998, 879).