When the Joint Commission is at the hospital, leave

When the Joint Commission is at the hospital, leave

Here’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind — surgery, or a diagnostic test — and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American health care facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve health care quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

American surgeons in 1918 started a system of reviewing hospitals because they were rightly concerned about serious differences in quality of hospital care and standards of practice. They wanted to evaluate hospitals objectively and motivate substandard ones to improve. In 1951, the American College of Surgeons joined forces with the American Medical Association, the American Hospital Association, and other corporate members to form the Joint Commission for Accreditation of Hospitals (JCAH).

As the organization’s scope of activities expanded, the name was changed in 1987 to the “Joint Commission for Accreditation of Healthcare Organizations” (JCAHO), commonly referred to as “Jay-co”, and then shortened to “The Joint Commission” in 2007.

The federal government didn’t pay much attention to health care quality until President Johnson signed the law creating Medicare and Medicaid services in 1965. Since the Joint Commission was already in the business of accrediting hospitals, the government decided to take advantage of the private sector’s expertise. Any hospital which passed Joint Commission review would be “deemed” worthy to take part in the Medicare and Medicaid programs.

Paying the Joint Commission to review their hospitals became much more attractive to hospital administrators once Medicare dollars were at stake, so more and more hospitals signed up. Today, the Joint Commission accredits and certifies more than 20,000 health care organizations and programs, encouraging them to feature its “Gold Seal” on their websites and advertisements.

A few competitors, such as the international firm DNV GL, have started to make inroads in the lucrative business of accrediting hospitals, but for the time being the Joint Commission holds a virtual monopoly in the U.S.

As recently as 20 years ago, a Joint Commission review was a benign experience for hospitals. The reviewers identified flaws or oversights that weren’t obvious, and made recommendations that actually improved processes of delivering care. Reviewers wouldn’t have dreamed of coming into the operating room during surgery.

As time passed, though, the low-hanging fruit was picked. Hospitals made major corrections, and national standards for many processes, such as sterilization of surgical instruments, were implemented. Hospitals across the country embraced the concept of continuous performance improvement.

Moving the targets

How could the Joint Commission stay in business? One answer is obvious: it can reinvent itself indefinitely by changing the rules and moving the targets.

Here’s a real-life example.

The Joint Commission decrees that syringes containing medications should be labeled with the name of the drug. No, that’s not good enough. All syringes should be labeled with the exact concentration in mg/cc as well as the name of the drug. That’s not good enough either. All syringes should be labeled with the drug name, the concentration of the drug, and the date and time they were drawn up. No, wait. They should be labeled also with the initials of the person who drew them up. And some medications should be labeled not with the time the drug was drawn up, but with the time it expires.

There is nothing to stop the Joint Commission from changing its rules ad infinitum,  guaranteeing reviewers jobs for life, and worsening the stress on hospital staff. While an external review could serve a useful function by sharing ideas and offering solutions, today it only scans for inconsequential details to cite as flaws.

Follow the recipe or treat the patient?

The Joint Commission benefits from the popularity of “evidence-based medicine” as a health care concept. Certainly it’s wise to use research evidence to guide health care decisions. But when the Joint Commission declares that evidence supports one treatment or medication as a standard of quality in health care, it forces clinicians to follow that recipe. If they don’t, the hospital will score poorly on its next review.

What if the quality of the evidence turns out to be poor?

Experienced physicians tend not to change their time-tested practices based on the latest study, as they’ve seen over and over that new data often fail to support an initial widely-publicized finding. They wait to see if the evidence can stand up to larger studies and closer scrutiny.

When you are a patient, you expect your physician to treat you as an individual. It makes sense to use research evidence as a guideline, not as a standard. For example, one Joint Commission standard of care is to give antibiotics for only 24 hours after surgery. This standard is tracked, and doctors are held accountable for meeting it.

But if you are a patient with diabetes or a poorly functioning immune system, you might be at higher risk for infection. You might prefer to trust your doctor’s judgment about how long you should be on antibiotics, without the specter of a Joint Commission review affecting the decision.

Physicians are pushing back against inflexible rules, realizing that they are management-driven, not patient-centered. Many patients have more than one medical problem. The application of a standardized protocol for one disease or condition may worsen another one. It takes physician judgment, and the knowledge of the patient as an individual, to make the best decision under the circumstances.

Meanwhile, at my hospital, the level of tension is rising as we anticipate Joint Commission review within the next few weeks. Experienced nurses are pulled away from patient care to make mock review rounds. Department chairs circulate memos about minute details that could trip us up. One chairman concluded succinctly, “These people are not your friends.”

As you think about the amount of the American GDP that is devoted to health care, remember that physicians and nurses would rather spend their time looking after patients than worrying about the next Joint Commission review.

And take my advice: Stay out of the hospital if you possibly can when the Joint Commission’s reviewers ride into town.

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.  She blogs at A Penned Point

Image credit: Shutterstock.com

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  • Dr. Drake Ramoray

    I have no love for the Joint Comission and try to see patients really early in the morning if I know an audit is occuring at the hospital as to avoid them, but to suggest that patients will receive inferior care because of an active audit (conceding your privacy point) seems to be little more than fear mongering. You would be better off to tell patients not to get sick on the weekend (good luck with that one) or not go to the hospital in July.

    I am not aware of any studies that show medical errors or issues are worsened by the presence of an active Joint Commissin audit. There are studies that show your worse off if you have a heart attack on the weekend.

    http://www.usatoday.com/story/news/nation/2014/01/21/heart-attack-night-weekend/4720559/

    And you are more likely to experience an error in July (new interns and newly promoted residents)

    http://www.aarp.org/health/doctors-hospitals/info-06-2010/why_you_should_avoid_the_hospital_in_july.html

  • QQQ

    “And take my advice: Stay out of the hospital if you possibly can when the Joint Commission’s reviewers ride into town.”

    ————————————————————————————————————-

    The Downgrading of the Medical Degree: The new world order under
    Obamacare will see a paradigm shift wherein government-empowered
    administrators and other non-physicians make de facto medical decisions
    effectively ruling over the practice of medicine by physicians. Through
    the abuse of “standards” imposed by the Feds, the AMA, and the
    pseudo-independent accrediting body, the “Joint Commission” (JCAHO),
    doctors are increasingly losing the freedom to exercise independent
    thought and the independent practice of their profession. By utilizing
    peer review practices which would not stand muster under standard
    constitutional law, hospital and health systems can label anyone a
    “disruptive,” “unruly” or “uncooperative” physician and destroy their
    ability to work.

  • Eric Strong

    This is obviously a minor point compared to the overall thesis of the post, but as a hospitalist, I happen to agree that syringes with meds drawn up into them should be labelled with the drug name, concentration, and date it was drawn up. More than once, I’ve stumbled across a random syringe sitting around a nursing station or MD work room labeled “Epi” or “Neo” – which seems like a bad outcome waiting to happen.

    • T H

      It isn’t all bad: I would think that most would agree that Joint Commission does have a couple reasonable ideas. And I think that most people would think that keeping the standards high is also a good thing… what most object to, however, is how the inspections are performed. And snap inspections (if both the hospital and JC were serious about their roles) would be part of it.

    • Karen Sibert MD

      I don’t disagree with you about the wisdom of labels for medications. However, even here the Joint Commission manages to exceed common sense and even act to the detriment of patient care. Here’s an example. On Wednesday I was taking care of a thoracic surgery patient, and there was sudden bleeding from a pulmonary vein. As I was transfusing blood and drawing up norepinephrine, I was distracted by a sense of annoyance that I would be “dinged” if one of the omnipresent snoops saw that the label “norepinephrine” hadn’t yet been dated, timed, and initialed. This was an unnecessary distraction in a complex situation. Yes, you can argue that it was an emergency and would be excused, but I would submit that as the ONLY person who was giving anesthesia to that patient, I knew perfectly well when each medication had been drawn up, and that I had drawn them up. Yet physicians and nurses alike these days are all treated as though we are criminals who just may not yet have been caught in our inevitable crimes. Who needs this type of aggravation? Can it be in the best interests of patient care?

  • Shirie Leng, MD

    Karen, I think your best point is the one about the moving target. If everyone follows the rules, change the rules. I also, on a lighter note, think it’s hilarious that all the equipment crowding the OR halls suddenly disappears on Joint Commission day and reappears after they leave.

    • leslie fay

      True. I specifically remember teams of people from housekeeping were tasked with pushing gurneys(the ones that lined the halls on a normal day)around constantly because you could not be zinged if they were not parked

  • Steven Reznick

    The same outfit that requires us to write at the bottom of the page of a progress note “Turn Page” on achart note that goes to the next page as if we haven’t turned a page before. Clearly a major safety issue worthy of a $7,000,000 inspection

  • Thomas D Guastavino

    One of my basic rules of life is “Never trust anyone who’s job it is to find fault with you” The reason is simple. If reviewers, like the Joint Commission, claim they have found nothing wrong they will be accused of not doing their jobs. For years I witnessed my hospitals go crazy trying to make everything perfect when the JC showed up. Instead, my advice was to purposely create a couple of small, unimportant things wrong that the JC could find. Then after the review, thank the JC for finding the flaws, and promise to correct it ASAP. Their egos would be served, they could claim they did their jobs, and everyone could survive another day.
    I won’t say whether this strategy worked, but I will say our reviews the past couple of years did seem to go a lot smoother.

    • T H

      Military units have used this strategy on IG’s for decades.

  • medicontheedge

    LOL… I find it just breathtaking how our hospital really cleans up when a visit is imminent, then things go “back to normal” when it is finished. If we only lived that way every day, it would not be such a big deal. I wonder how t would go if JHACO, DPH, etc, visited in a surprise inspection!

  • buzzkillerjsmith

    I thought you meant doctors should stay away when the inspectors are lurking. That’s good advice too.

  • rbthe4th2

    I find this interesting. As patients we look at JCAHO as being garbage and not worth it and a joke.

  • leslie fay

    I am a retired respiratory therapist who over my career had the misfortune of participating (on various levels)in more JACHO inspections than I care to remember. Like many things in life the original concept to improve pt care was a good one, but that was long ago lost in the shuffle. I agree they have moved on to nit picky deluxe as well as some completely crazy ideas-the limitations/documentation on restraints leaps to mind. But far and away my biggest gripe is the fact that everyone KNOWS when they are coming and so as you point out everyone is on their best behavior. If they showed up unannounced they would certainly have a more accurate view of what happens day in and day out. As it stands now it’s just a very expensive fire drill.