Quality improvement projects: attributing variation between physician and nonphysician causes

Healthcare systems may be unique among the systems that have used a total quality management (TQM) approach to improve quality. The physician is considered centrally placed within the system, because most, and possibly all, core processes are driven by physician decision. A conceptual approach is offered to aid early understanding and success in improvement efforts. This approach is to begin TQM efforts with a distinction between physician causes and all other causes of variation. The example provided is a collaborative, clinical, quality improvement project with six acute-care facilities involving hip fracture surgery. In this project, the process of interest was the prevention of thrombus formation. The variation in facility performance on this indicator was split into two parts: physician and nonphysician. The variable "nonphysician" included all other causes of variation. Facility responses to this presentation are recounted.