I have spent years watching the development of quality programs. What began as a way to ensure patient safety has gradually given way to an independent group of individuals whose job it is to interpret regulations and monitor those interpretations. In the process, the clinical richness of medicine has been lost. Judgment, narrative, and context matter less than forms and metrics. The work has shifted away from the bedside and toward documentation, and something essential has been left behind.

The laws of quality

Below are some of the “Laws of Quality.”

1. Show me a quality officer who only triples my work, and I will kiss their feet. The amount of time spent gathering data, meeting about data, and checking off forms inevitably consumes an excessive portion of our day. The reality is that most physicians now spend roughly two hours on charting and other desk work for every hour of direct patient care.

2. When Quality tells us it is pursuing evidence-based interventions, what it usually means is that the form can be completed reliably. Evidence of improved outcomes is optional. I recall attending a meeting on suicide prevention where the head of quality reported that completing the Columbia Scale was an evidence-based intervention. Being the cynic that I am, I asked for the citations demonstrating this. They were promptly provided. The study showed that staff could complete the form reliably and that implementation cost only $200,000. I did not have the heart to point out that when I asked about evidence, I meant clinical evidence.

3. Even when the forms are filled out perfectly, on time, every time, bad things still happen to patients. I complete the Columbia Scale. I complete the psychiatric evaluation. I document carefully, on admission and discharge, the absence of suicidal thoughts, plans, or intent. And then I learn that the patient has killed themselves.

4. The most reliable response to any adverse event is the creation of a new form. When I was vice chair of clinical services, a patient discharged from the clinic and referred elsewhere later died by suicide. The physician had not documented the referral in the progress note, though it was clearly present elsewhere in the medical record. The response was not discussion or supervision. It was a new form, embedded as a hard stop in every progress note, to be completed every time the patient was seen.

5. Once a form exists, it will outlive the problem it was created to solve. That same form still exists 20 years later. So does the Ebola screening form.

6. There is no such thing as a “never event.” These events happen, or they would not need to be named. Just because regulatory agencies declare that something should “never” happen does not mean that it will not. We speak confidently about “Zero Suicide,” yet suicide rates in the United States continue to rise.

7. Once the measure becomes the focus, the patient is forgotten. The chart, along with all its forms, becomes the center of care. In psychiatry, the patient is defined not by checkboxes but by narrative, history, and meaning. I supervise many residents who have completed every required form flawlessly, yet cannot tell me anything clinically meaningful about the person they are treating.

8. The farther one is from the bedside, the more the metrics matter. The ability of quality staff to understand the limitations of these measures diminishes with distance from clinical care. Removed from the bedside, all that remains visible are numbers. The patient behind them disappears.

9. Every fix will inevitably restrict the rights of the patient. During a Joint Commission survey, a surveyor noted graffiti on a wall. Patients are given pencils to journal, write menus, and record phone numbers. The solution? No more pencils. In another case, a patient scratched themselves with a plastic knife. The fix was to eliminate utensils altogether. That one, at least, was ultimately beaten back by clinicians. The list goes on.

In the end, we as clinicians are forced to accept that it exists and hope that we can modulate it to the realities of clinical practice.

Constantine Ioannou is a psychiatrist.