Daunted by the seeming impossibility of measuring and comparing hospitals on real outcomes (given our primitive state of data collection and heterogeneity in patient populations, among many other challenges), well-meaning bureaucrats and non-profiteering safety advocates like the Institute for Healthcare Improvement have created directives based on surrogate measures in an attempt to standardize and improve medical care. Despite their seeming authoritative base, these guidelines have almost without exception been constructed on an evidence base that's suggestive, but hardly sturdy. In the absence of anything more reality-based, though, payers and regulatory agencies have put their collective shoulder behind these "quality" guidelines, whose momentum has compelled the participation of physicians and created large-scale shifts in clinical practice. Unintended consequences ensued: Holding hospitals accountable to a 4-hour window to deliver antibiotics for community acquired pneumonia led to