Clinical Futile Cycles: Systematic Microeconomic Reform of Health Care by Reform of the Traditional Hierarchical Referral Model of Care

The incidence of adverse patient events in hospitals has not improved over the last two decades despite enormous efforts in the area of Quality and Safety. Notably, the same errors are often repeated, even though previous reviews of these events have resulted in learnings, guidelines and policy. The traditional review of a Hospital Adverse Event (HAE) is most commonly a Root Cause Analysis (RCA) to find factors and conditions that caused or contributed to the HAE. The basis for the RCA is the James Reason Swiss Cheese model of adverse events developed from analysis of large- scale industrial accidents. In this model the HAE occurs when a patient deteriorating clinical trajectory broaches the hospital's organisational and professional defences. The learnings from the RCA typically result in new or changed policies and procedures, and occasionally professional disciplinary review of the involved health care workers. Clinical Futile Cycles (CFC) is clinical action or intervention (or lack thereof) that has no patient benefit. Analysis of HAE by looking for CFC creates learnings that focus on the human factors of the involved health care workers, and more importantly the socio, politico, and fiscal cultural hospital environment at the time of the HAE. As such, the learnings focus not on limitations of the individual practitioners but rather, the greater environment that has them often ignoring, broaching or being oblivious to professional standards, and the already existent policy procedure and guidelines.