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Feedback is an electrical engineering term that has crept into general usage. As used here, it is the means by which the output of a process affects earlier steps in the process. Feedback is positive when it stimulates the process, and it is negative when it inhibits the process. In the context of quality control theory, feedback refers to the effect that changes in the odds of certain events occurring have on the odds of other related events occurring.

The problem of ensuring medical staff competence is a good example of feedback. It is common observation in any large community that different hospitals develop different "personalities." Sometimes this just means different approaches to medical care, but often it means a different quality of care. These perceived differences in health care quality are caused by feedback. This occurs because the physicians delivering the medical care are also the persons charged with ensuring the quality of the care. If they are diligent in disciplining incompetent colleagues, the incompetent physicians will tend to move to less demanding institutions. As a the general level of competence of the medical staff increases, there will be more support for the disciplining of incompetent staff members encourages the enforcement of quality control rules, which leads to the removal of other incompetent staff members.

Unfortunately, this process can also work in reverse. A hospital can experience a decline in the quality of its medical staff because of an ineffective medical staff committee. Once the enforcement of standards slackens, the hospital will attract more marginal practitioners. These marginal practitioners will in turn resist the enforcement of the quality control standards, thereby encouraging other marginal practitioners to join the staff. This deterioration in the quality of care can result in significant legal liability if it delays the acceptance of new legal duties. In the usual course of events, there is a five- to ten-year inertial period between the development of a new legal theory (such as hospital liability) and its adoption by the majority of the legal profession. It is this inertia that provides the greatest challenge to quality control. The problem is that the recognition of important new risks will be delayed by the lack of litigation pressure.

The delayed acceptance of new legal theories results in a period when the hospital is potentially liable for the consequences of the risks created by the new theory, but the probability of being sued is still very small. The hospital may use one of several strategies in this situation. It may:

implement an effective quality control program, accepting that it will not appear to be cost-effective until the level of litigation increases;

continue the status quo, saving money initially but losing money in the longer term; or

implement a limited (sham) quality control program that will appear effective because of the low probability of being sued.

The implementation of sham quality control programs is the usual response to a new legal duty. The most common example of a sham program is the establishment of an incident reporting system without establishing a method of preventing the identified risks. This can be the most financially risky choice if it delays the implementation of an effective quality control program while it documents risks that are not properly managed. It is this type of delayed action that leads to pipelining.

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