Decision Journal Template: The Six Fields a Boston Surgeon Invented in 1914

Ernest Codman was removed from two rooms for asking the same question, but only the second removal matters here, because it produced the first decision journal template anyone wrote down.

In 1910 he brought a proposal to the trustees of Massachusetts General Hospital. Staff appointments and promotions should rest on audited patient outcomes. The trustees rejected it. He resigned his staff appointment in 1914, bought a brownstone on Marlborough Street in Boston, and opened a twelve-bed hospital where every patient was followed and every complication was recorded.

Between 1911 and 1916 he documented 337 surgical admissions. In 1918 he published the case report, disclosing and analyzing 123 errors.

The instrument was a card. One per patient, six fields, filled in "in the briefest possible terms," as he put it in the report itself. The symptoms the patient came in with. The diagnosis treatment was based on. The plan of treatment. The complications that followed before discharge. The diagnosis that proved correct. The result each year afterward.

Two of those six fields carry the entire idea. The diagnosis treatment was based on is what the doctor believed before he acted. The diagnosis that turned out correct is what was true. Written on the same card, a year apart, they show the gap between reasoning and the world. That gap is the only thing worth reviewing, and it stays invisible in a log that records only what happened.

Codman stated the method as six questions.

What was the matter? Did they find it out beforehand?

Did the patient get entirely well? If not, why not?

Was it the fault of the surgeon, the disease, or the patient?

What can we do to prevent similar failures in the future?

Translate that to a company in six lines.

What did I decide? What did I believe when I decided it?

What did I do? What went wrong on the way?

What turned out to be true? Whose fault was it: mine, the market, or the customer?

The second line is the one founders skip. A decision logged after the fact, with the belief already contaminated by the outcome, is a memory, and memory is generous. Codman made the belief a required field because the belief is the part that gets rewritten.

Then the review. He wrote that a service of 60 beds can be reviewed in one hour a week. Founders read that as a line about hospitals. It is a design constraint. One hour, one week of decisions, each marked with a symbol instead of a paragraph.

The rest of the story is what it cost him. In January 1915, at the Suffolk District Medical Society, he presented an eight-foot cartoon of the Boston medical establishment as an ostrich with its head buried in the sand.

He was removed as chairman of the surgical section. His own hospital never made money. A 2014 review in The American Surgeon records that his colleagues did not appreciate the concepts that later became basic quality tools, and that he is now described as a visionary.

The minimum standards his committee wrote for the American College of Surgeons became the foundation of modern hospital accreditation. The card, and the six fields on it, survived everything the politics did to him.

A decision journal template is not a clever format. It is two lines that force you to write down what you believed before you were allowed to know better. Codman published his in 1918. Copying it takes about ninety seconds, which is the point.