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Many emergency departments (EDs) and their hospitals have developed response plans for coping with sudden, unexpected mismatches between treatment capacity and patient demand. In this issue of Annals, Back et al analyze a sample of these formal “escalation policies” from a heterogeneous group of English EDs and perform a detailed analysis of how one such policy actually played out in practice at one large ED. They found that organizational policies aimed at addressing operational problems are often unused, unusable, or ineffective, at least in their literal form. Policies and other forms of prescriptive, feed-forward guidance (eg, procedures, regulations, guidelines, rules, protocols) are essential components of modern organizational life, supporting efficiency, rationality, and coordinated effort. At best, policies are distillations of accumulated experience, not so much rules but rather resources for action. However, because nothing persists for long in social systems unless it benefits someone, the presence of unused, unusable, mutually contradictory, or ineffective policies raises the question of what benefits they provide, and to whom. This question requires unpacking the role of policies in care delivery organizations to identify the unexpressed purposes they address in addition to, or even instead of, providing prescriptive guidance. Sociologists have long remarked that institutional polices can be aimed not only at improving the efficiency or safety of production but also at the need to establish legitimacy—to publicly demonstrate to the outside world that this is a responsible organization using socially accepted methods in pursuit of desirable ends. In this sense, some organizational policies are performances for the benefit of external audiences that only incidentally might be useful as guides to action. In otherwords, sometimes policies are created with no real intention they would ever be used in practice. This performative aspect of policies brings with it 4 problems. First, it requires “.decoupling arrangements produced in order to achieve legitimacy from those necessary to support concrete work activity.” Back et al found this