Clinical Variation Each patient receiving an identical diagnosis might not be given the same treatment. This is known as clinical variation, and can be broadly categorized as falling into two types. One is necessary clinical variation, an alteration in medical practice that is required by the differing needs of individual patients. This modification may be in response to differences in the patients themselves, because of age, overall health status, or other clinical characteristics; or it may be caused by differing desired outcomes as part of a patient-centered approach to care (8). This kind of variation is expected in any system of care. The other type is unexplained clinical variation, which comprises differences in medical care and patient management that are not accounted for by differences in patient symptoms, objective findings, or patients’ goals for care. These treatment discrepancies could account for wide variations in the cost of care without any demonstrable difference in outcomes as measured by morbidity or mortality
Table 3.1 Six Aims for Quality Health Care
Role of Organizational Leadership (9–11). Often this unexplained variation is the result of management choices made by physicians in cases that fall into so-called clinical gray areas, where no single course is clearly correct. Sometimes this variation is both unexplained and unintended. It is this unexplained or unintended variation that is considered one of the greatest barriers to the delivery of consistently high-quality care (12). The specialty of gynecology is subject to this treatment inconsistency. Significant geographic variations in hysterectomy rates, largely unexplained by the clinical characteristics of those local populations, were reported (11,13). Further study and reduction of unnecessary variation in these rates could contribute to making medical care more efficient and equitable.
Creating a safe environment for the delivery of medical care requires the active participation of organizational leadership. Each physician assumes a significant responsibility for safety and excellent care in his or her own practice environment. In the hospital, oversight for issues of safety and quality is shared by the hospital board, executive leadership, and physicians who serve as chief medical officer, vice president of medical affairs, or department chairs. A new position being adopted by many hospitals is the patient safety officer (14). This individual takes direct responsibility for overseeing all aspects of the hospital patient safety program and reports to the hospital chief executive officer or board of directors. It is an emerging role for physicians who want to make patient safety the focus of their professional lives.
An integral part of promoting patient safety is the creation of an organizational culture where patient safety is recognized as everyone’s responsibility. Culture in an organization is “the way we do things around here” mindset, and it reﬂects the attitude of the members of the organization toward what is important and how that fits into the structure of their activities (15). The first step in creating a culture of safety is to measure a starting point for both nursing and physician staff regarding the attitudes and perceptions around patient safety. This can be accomplished using any of several validated tools such as a safety attitude questionnaire or hospital survey on patient safety culture (14). Once areas of deficiency are identified, steps can be taken to improve culture by direct interaction with frontline clinicians to ascertain appropriate changes to the clinical environment to promote safety. This can be done through regular safety meetings or direct observation of the workplace with Executive WalkroundsTM (16).
Another method for improving the safety climate in a hospital is the adoption of the tenets of “Just Culture” (17). Just Culture recognizes that human error cannot be eliminated from any complex system such as health care. People sometimes make mistakes. They can be held accountable for following procedural rules to reduce harm to patients resulting from human error. Adverse outcomes and near misses allow the organization to examine its processes of care with an eye to continuous improvement. With such a system in place, the reporting of safety problems and concerns will often increase dramatically. This in turn allows the hospital or other health care organization to initiate programs to address these issues and to make “first, do no harm” a reality.