• clinical governance
• Continuous Quality Improvement
• evaluation
• peer review
• quality of care

In your editorial on clinical governance, you cited “fragmented...evaluation” and “lack [of]...benchmarks of quality of care...which...impairs...improvements in patient care.”¹ If improvement in patient care is impaired, clinical governance is conceptually moribund.

Clinical diagnosis consists of evaluating patients’ maladies— “[A]t the heart of [clinical governance] is the desire to evaluate the quality of medical practice against agreed standards”¹—and thus entails an analogy between clinical evaluation of patients and performance evaluation of physicians. The clinical biochemical literature identified a deficit that renders that analogy false: “...total quality management (TQM) in laboratory medicine [requires]...that objective quality goals must be clearly defined a priori...”²

Obviously, an evaluator can compare care he examines with quality benchmarks in either laboratory or clinical medicine only if he has a clear, a priori, definition of quality of care in mind. Mechanistic goals of laboratory medicine may be amenable to a priori definition, but the more subjective, viewpoint dependent goals of clinical medicine are not, as Steffen inadvertently demonstrated as he sank into a conceptual quagmire in his attempt to define quality of medical care.³

Another logical bind little noted in the medical literature is that performance evaluation of individuals is counterproductive of Continuous Quality Improvement (CQI/TQM), because it instils fear and erodes morale,⁴ so clinical governance, reliant on CQI, is likewise incompatible with it. Deming implemented CQI by substituting leadership for performance evaluation. Leadership, unlike performance evaluation, is compatible with collegial principles governing professional development in medicine.

Besides, the clinical assessor too often errs because of the customary procedure in medical peer review: without having examined the patient in question, he relies on the relevant clinical chart alone in his attempt to evaluate a physician’s performance.

Accordingly, it is small wonder that “there is...little published evidence that clinical governance makes any...difference.” The foregoing fundamental internal contradictions render clinical governance unworkable.