From a background in Australian intensive care medicine, Buist and Middleton have written critically of the rise and expense of the quality industry:
“In 2007, I [MB] published a theoretical construct of adverse events called “clinical futile cycles” to challenge the James Reason “Swiss cheese” model. In Reason’s model, an adverse event occurs when “holes” in organisational defences (represented as slices of Swiss cheese) align to allow a “trajectory of accident opportunity.” In my construct, healthcare adverse events occur not because of ignorance or inability but because of the circular way that staff apply the unwritten rules and work practices that exist in healthcare. This circular thinking or clinical futile cycles that staff use to try to solve the problem prevents escalation to the next level in the clinical hierarchy. This continual cycle of clinical thinking and action is slow and consumes valuable time when confronted with a deteriorating patient. To a certain extent this construct has been validated by my own work and that of others. That said, there are few objective data about the way in which doctors go about their day to day work of looking after patients…
This is not the UKAS/ISO assessment regime of tight behavioural control which is coming to clinical measurement, but it describes similar cycles of futility. Writing manuals and recording everything possible so that it can be inspected. Changing the paperwork to say you do what the assessor wants despite it not being in the ISO standard. Doing it all again next year over a different selection of issues that would have been corrected earlier if they actually caused problems.
Without paperwork to feed their paranoia the assessors know they would be out of a job. That’s why third-party assessment was invented in the first place. That’s why its effectiveness is never properly assessed. Perfection is the last thing they want. Merely “delivering confidence” is much more suitable.