Assessment of quality in health care has a long history, dating back to the works of E.A. Codman, who wrote in 1914 about improving the quality of care by evaluating the results of treatments.1 These views were not widely accepted at the time. Codman experienced considerable frustration in persuading his colleagues to keep accurate records and note the outcomes of their treatment. Ultimately, he resigned from the staff of the Massachusetts General Hospital and formed his own hospital, where he diligently kept records of his surgical procedures and patients' outcomes. Codman's ideas concerning outcome-based quality improvement were not considered seriously again until the 1980s. In the interim, many physicians regarded the quality of care they provided to be high, but they could neither define nor measure it exactly. This attitude toward quality perhaps is illustrated by a quotation from Pirsig's Zen and the Art of Motorcycle Maintenance: "Quality.... you know what it is, yet you don't know what it is....But when you try to say what quality is, apart from the things that have it, it all goes poof! There is nothing to talk about. But if you can't say what quality is, how do you know what it is, or how do you know that it even exists?"2

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