Sometime in the past couple of months JCAHO paid an unannounced visit to my hospital. I should have known something was up when I saw our Chief Medical Officer up on one of the medical floors talking excitedly to an old man in a suit. My naïve self assumed he was interviewing a new physician…no matter how ancient he looked…one we really wanted to recruit. The second clue should have been the basement hallways suddenly being devoid of broken down beds and other equipment. But once again, my head was in the clouds or rather deep in thought about the patients I was about to see. It was only when I was up on another medical floor and I heard a nurse whisper an announcement that “the suits are coming here next” and the unit secretary proceed to remove charts from the floor in a frenzy did it occur to me that an inspection had befallen us.
JCAHO, pronounced jay-co (I know, totally intuitive), stands for the Joint Commission on Accreditation of Healthcare Organizations. It’s now known as The Joint Commission (TJC) but we still call it jay-co. It is a not-for-profit private organization in the United States founded in 1951 whose members are health care organizations such as hospitals. Its purpose is to accredit these health care organizations…for a fee, of course.
In simple English, a hospital pays for the privilege of having JCAHO/TJC descend upon them unannounced every three years to do an inspection (audit and surveys) of their practices. It is entirely voluntary however be forewarned. If you are a hospital in America that wants to stay in business by participating in Medicare, the largest insurance program in the US, you better have a Joint Commission accreditation so that the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) can decide your eligibility.
Now, all that sounds dandy, but it is no secret that health care professionals detest the rules set by The Joint Commission and their micro-managed inspections. Why? Because practicing medicine is hard enough without some bureaucrat telling you one year things must be this way then telling you the next year it must be that other way.
Essentially, The Joint Commission is the Transportation Security Administration (TSA) of hospitals because any theoretical risk leads to a rule. No matter how illogical that rule is or how much the rule impedes patient care it will be enforced rigidly and without questions. These are rules typical of bureaucracies. Illogical rules that prevent guaiac cards and guaiac developers from being stored on a medical floor, emergency room, or intensive care unit for example. Apparently, it’s a lab test, therefore only the lab can run it. As a resident, when we happened upon a stash of cards or a bottle of guaiac developer that had not yet been confiscated, we kept them because who wants to wait two hours for the lab to receive and process a specimen then report back to you that your patient’s stool is guaiac positive (ie. there is blood in the stool) when you could do it yourself at the bedside in 2 seconds and go ahead with timely patient care? Seriously!
I know they mean well, I mean they have to mean well, but really, some of the rules that can get a hospital dinged are so annoying. Another example? One needs two patient identifiers before caring for a patient at all times. That means if I see Mr. Smith today, I have to introduce myself (duh!), then ask him his name and his date of birth and confirm that with his wristband. Fair enough for first encounter, although woe is me if slightly demented Mr. Smith tells me his birthday is 12/8/2010 instead of 12/8/1922 because technically I now have to find somebody to confirm that he is actually the Mr. Smith I’m here to see. Yeah!
But if today is day 14 in a row of me seeing a non-demented Mr. Smith why do I have to confirm his name and date of birth and make sure they match his wristband? If I just saw him 2 hours ago and now I’m back to give him more results, why do I have to go through all that again?
Patients already get angry when I am consultant doctor #5 asking them why it is they are in the hospital, did they have any fevers at home, and what their allergies and home medications are. I can’t count the number of times patients have huffed and puffed at me, yelling “what’s wrong with you doctors, don’t you talk to each other, don’t you read the charts, I done already told the other doctor blah blah blah”. If only they knew….
What does it mean to be certified by The Joint Commission?
Is there any proof that being certified by them translates into better patient care? Who regulates The Joint Commission? How do obviously illogical rules not get challenged?
My hospital was closing in on its 3 year period from its last survey and therefore people were in “ready mode” anticipating this visit any time soon. But still there was a lot of hustle and bustle when The Joint Commission finally did arrive to make sure everything was meticulous. The stress, apprehension, and heightened state of awareness was enough to give anyone heartburn. It was all about paperwork, procedures, and little about real patient care.
As chair of my department I was intimately involved with The Joint Commission inspection. We sat and listened to what the surveyors had noticed about our hospital, both good and bad, and then we went up to a floor to choose a random patient to evaluate the care they had received in the hospital so far. Or rather I should say to evaluate the DOCUMENTATION of the patients care.
Did the doctor write legibly? Were abbreviations used? Are all orders timed, dated, and signed? Then, the group descended on the chosen patient and subjected him to questions. Did your nurse introduce himself to you today? Did you see this contact isolation sign on your door and did anyone explain it to you? Do you know what medicine is hanging in your IV right now and why you are getting it?
Then, any random health care worker we came across was subjected to questions. To the temporary personal care assistant, how long do you disinfect that glucometer for? To the transporter, how do you know that this is the patient you are supposed to transport? During the entire process, I wondered whether The Joint Commission was above HIPAA regulations. And I dreaded the responses, because any wrong answer from any employee is enough to get the hospital cited. Get cited enough and a hospital can lose its accreditation.
However, overall the process went smoothly. When they finally did leave it was a huge collective sigh of relief. We survived! Patient care as usual again!
In conclusion, as a resident, I thought some of the rules were nonsensical (see guaiac processor discussion above). As a practicing physician with some inside knowledge, I find that most of these rules though well-meaning in some degree do nothing but impede timely patient care. In addition, they increase paper-work and decrease cost-effectiveness. All this for a self-paid voluntary inspection by a private organization who makes its own rules.
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