The Quality Dilemma

My sincere appreciation to Drs. Ban, Gunter, and Kanters for an outstanding volume on quality in colorectal surgery. At my current institution, the Cleveland Clinic, our CEO always preaches that everything starts and ends with ensuring the highest patient safety and quality outcomes. Patient experience is also critical, as are other factors such as systemness, uniformity of care, and value. However, safety and quality of care are paramount. So why are things so variable? Caregivers and medical institutions certainly do not want their patients to have poor outcomes. As a surgeon, I tell my patients that while I cannot guarantee they will not develop a complication, we will strive to do the right operation, for the right indication and ensure that we as a team will do everything we can to ensure the patients gets through the operation as best as possible. Further, outside of the patient and their immediate family and friends, the person they are looking at (i.e., me) is the person most vested in them achieving a safe and great outcome. Unfortunately, morbidity and mortality still occur. There are also differences in outcomes, individually and institutionally, that are widely disparate for similar patients undergoing the same procedure. More concerning, some of these outliers remain outside of the normal curve—even in poor outcomes—repeatedly. The dilemma then lies in what can or should we do about this discrepancy. The answer(s) are more nuanced than apparent at first glance.