Quality management (QM), utilization management, and risk management each evolved in response to different external demands. Practices that evolved in response to the real or perceived influences of accreditors, regulators, and payers may be easier to modify if we understand their origins and can identify why those practices are or are not warranted in today's environment. Also, if an individual works exclusively in one of the three traditional areas of quality (QM, utilization management, and risk management), history provides insight into the demands faced by individuals working in the other two areas. Finally, history should be of interest as we prepare for another wave of healthcare reform, which may result in additional changes in our QM organizational structures. This article traces the roots of quality management, utilization management, and risk management for their impact on the organizational structure of hospitals, and summarizes the most common current design variations employed for different situations.