Ernest Amory Codman and the End Result Idea in Surgical Quality

The quality movement in 21st century healthcare—quality, patient safety, and the value equation (value equals quality divided by cost)—had their start with Ernest Amory Codman (1869-1940), the quixotic surgeon who started it all a century before. He was on track for prosperity and success, given a Boston Brahmin pedigree and his impeccable credentials from Harvard College, its medical school, and the Massachusetts General Hospital. In 1910, nearing 40, Codman instead detoured toward a revolutionary idea that he called the End Result system, the seemingly unachievable goal of reaching “perfection” in surgery: complete recovery without death, complications, or lasting disability. He scrutinized any case that fell short, seeking honest explanations and improvements so that his next case would more likely reach a perfect outcome. The system that was so clear to him was audacious to his colleagues, who summarily rejected it. When Codman suspected greed and self-interest, he was ostracized from the Boston medical community. To apply his concepts, he opened a proprietary hospital called the End Result Hospital that drove him to insolvency. His career never recovered from the debacle even when he later reached prominence as an authority on bone malignancies and shoulder pathology. When he died, his resting place went unmarked. As quality became central to healthcare at the end of the 20th century, Codman’s prescient End Result system was recognized as a fundamental contribution to medicine.