What being overwhelmed by rules and regulations looks like

My morning practice session started out with a few patients arriving early, so I was able to get a jump on the day, and it looked like I was going to actually be running on time.

As I was walking from one exam room to the other, my administrator came down the hallway, grabbed my arm and said, “Can I have you for a minute?”

It seems that a group of systems analysts from our patient-centered medical home team had arrived, with an urgent need for some documentation. They had received an urgent audit request from the National Committee for Quality Assurance (NCQA), and they needed to find a particular instance of a particular type of care management action, and documentation needed to be sent back to them that day.

They said they needed an example of a critical lab value, and its reporting from the lab to the care team, and then a clear documentation of the follow-up to resolution of that critical lab value, linking the patient to their care team members in the action plan in the electronic health record (EHR).

Could I point them to a chart of a patient who had a critical lab value?

Now, we’ve all seen more than our share of critical values, markedly abnormal labs that require the lab personnel to contact a live human being. Since before we were interns, someone on the phone from the lab has called us, reported a positive blood culture, a potassium of 1.9, a white count of 140K, a glucose of 950, and then politely asked, “What’s your name, doctor?” Later we find our name written against the lab value in the computer. This is what is known as “MD aware.”

I spent a few minutes with our administrator, explaining this, and helping him try to figure out how we can look for this. We ran our diabetes dashboard, and looked through the patients with the highest HgbA1c values, and looked at their initial readings when they were first diagnosed, which would likely have led to some critical lab value being located in the system.

We ran the dashboard report, looked back through the week’s practice, saw the patients who had poorly controlled diabetes, looked back at the date the patient with the highest HgbA1c (14.6%!) was diagnosed, and found a glucose reading of well over the critical value reporting threshold for the lab. Looking at the EHR for that date we saw the phone conversation between the lab tech and our overnight on-call provider, and all the documentation they needed was there.

We took this to the patient-centered medical home team, and they said we can’t use this one, they are using diabetes care management for a different part of the audit, we need some other lab.

I stopped, took a deep breath, and thought for a minute. It turns out it is hard to reverse-engineer figuring out who had another dangerous critical range labs value.

Let’s look for someone with severe anemia, and look back through all their hemoglobin values to when they had a critically low value. We were not able to access this through any of the patient databases, but luckily (?) I have plenty of anemic patients to choose from. I pulled up the lowest hemoglobin found in our practice in the past few months, looked at the notes from the date it was diagnosed to find the appropriate reporting from the lab to the providers, and the ongoing management of this problem moving forward.

Problem solved. Back to my patients.

Or not.

As I headed back from my office to the exam room, I was intercepted by the Joint Commission advance team from the hospital. These are members of our staff who are on-site in advance of the Joint Commission survey which is happening on our campus at the moment. They corralled me and took me into an office to ask me some questions, to see if I was Joint Commission-ready.

Just so you know, I’m going to burn in Joint Commission hell.

What does RACE stand for, she asked? Wait, no that’s too easy, let me give you something else. Of course RACE is part of the fire safety protocol — it stands for rescue, alarm, contain, extinguish/evacuate — but the joke around here is that it stands for run and catch elevator.

“What is a code gray?” she asked.

I wasn’t sure — a missing/eloped elderly patient from the inpatient ward?

No, that’s an eloped psychiatry inpatient.

Well we don’t usually have those here in our office, and we don’t hear those overhead announcements either.

That does not matter, you have to know what they mean.

“What is a code pink?” This one I knew, a missing child from the pediatrics inpatient floors.

“Correct. Up to what age?”

I answered, “Up to age 21.”

“No,” she said, “only up to age 17.”

But the pediatric service has patients up to age 21. “What is the code for patients between age 17 and 21?” I asked.

She did not know. Instead she asked me, “What’s a code freeze?”

I resisted the temptation to say that it was an overhead announcement that ice cream was available in the cafeteria.

“I do not know,” I said.

It is the overhead page announcing that someone has a weapon in the hospital.

And what am I supposed to do when I hear this?

“Nothing specific, you just need to know what the overhead page means,” she said.

Oh, and by the way, I’m not allowed to have my water bottle or coffee cup on my desk, the candy jar on the table in my office, or the bottle of wine behind my desk the patient gave me that morning as a gift. These have to be hidden to satisfy the Joint Commission surveyors who might be coming by my office.

Definitely burning in hell.

Well, by now I’m running really late for my practice session, my patient has been shivering in the exam room in his gown, waiting for me to return to once again clear him for cataract surgery (he tolerated the procedure he had on the other eye last month without any problems).

I know, I need to know how to safely evacuate patients from our practice in the event of a fire, and I know that I should not use oxygen tanks as doorstops, and I know now that we cannot store things within 18 inches of the ceiling or the sprinklers will not work (we do not have sprinklers in our office), and I surely want to know if someone is walking around the campus with a weapon seeking to do mayhem to our staff and our patients, but all of this stuff seems to really just put me farther and farther behind schedule, and cannot be making my patients the center of my day.

Once again we as providers are overwhelmed by rules and regulations, the mandates that come to us from outside certifying organizations, government agencies and licensing groups, who clearly may be working with the best of intentions, but are driving us clinicians up the wall and away from care.

As we continue to build a more patient-centered medical home, and in doing so transform this health care system that is so severely broken, let’s see if we as the providers of care can help clear the waters, take back control of this system that we joined to care for patients, and become leaders of finding a better way to heal our patients and this country.

Really, checking for expiration dates on boxes of tongue depressors? They’re wood!

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

Comments are moderated before they are published. Please read the comment policy.

  • SteveCaley

    It is beyond coincidence; it is beyond misunderstanding. You know that. They are doing this on purpose, you know that – and they don’t care about the consequences.
    The power to wreck remains within human experience, has broken out in human history time and time again. We see the bonfire being lit, it is no accident. There is a grim mask, of setting things right, that overlay cruelty time and time again in history.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Just a minor observation:
    There is absolutely nowhere in the NCQA PCMH Standards that critical lab values are even mentioned, let alone required to be addressed. There are requirements to illustrate processing of abnormal lab results, and an example of that should have been readily available, without physician intervention, from the simplest tickler list, which every practice has in one form or another.
    The moral of the story is that having teams of analysts, that are external to the practice, build your medical home is not the best or most efficient way to go about it.

  • J Rizzo

    At any given hospital, on any given day, these clinical environments have more in common with the movie “Brazil” than they do with reality. The stupidity at work is not unreal, it’s surreal. Its hard to believe administrators, management and my fellow clinical peers who go along with all this crap are adults not even stopping to question the sheer insanity of an unstoppable bureaucracy. If in documentation or under questioning you miss one sub clause under sub section 3.9 you are deemed not only NOT a team player but also incompetent. “Do you want someone to run out of here with an psychiatric inpatient neonate?” (otherwise known a a “grey blizzard”). I DON’T CARE!!! ALL THAT YOU SPEAK IS JIBBERISH!

    • SarahJ89

      Brazil. You are correct. Somehow we’ve all moved to Brazil.

  • J Rizzo

    One more thing- thanks to our genius EMR system this week all my patients have documented in their EMR that they 1) have had a recent episode of eating poisonous frog meet and 2) GPA of 5/3/2. Including the males. Nobody knows why this happened or how (myself included). I don’t ask any of my patients if they recently eating poisonous frog meat. I don’t ask my male patients if they have ever been pregnant. Oddly, administration simply shrugged their shoulders. Thanks for letting me vent

  • QQQ

    “Why Doctors Are Sick of Their Profession”

    “American physicians are increasingly unhappy with their once-vaunted profession, and that malaise is bad for their patients”

    http://online.wsj.com/articles/the-u-s-s-ailing-medical-system-a-doctors-perspective-1409325361?ru=yahoo?mod=yahoo_itp

    • buzzkillerjsmith

      I read the piece. This guy goes over all the bad stuff that we already know about. Then, sure as shootin’, he goes over the solutions. Meaningful this and that and the other.

      He’s a moron or a scammer,, educated, yes, but with weak powers of analysis. Or someone who, most likely for money and influence, won’t draw the conclusions that need to be drawn.

      There is no hope–at least in the short term. Why is that so hard to admit?

  • Brailleyard

    So it leads me to ask, would any of these problems be lessened by the presence of an MD/MBA in Administration? – someone who’s primary goal is to ensure that Doctors get to do what they spent/sacrificed so much to do?

    In short – what method do we as [future] doctors have to improve this?

  • southerndoc1

    “a group of systems analysts from our patient-centered medical home team”

    No commentary needed.

    • T H

      That phrase…. does say it all.

  • JPedersenB

    I’ve said it before and I’ll say it again. Doctors must take back their profession! I don’t know how that will happen as far too many MD’s have been cowed into submission by the relentless stupidity of the regulators and their minions.

  • doc99

    Fred, you can start to take back the profession by eliminating the term “Provider” from your lexicon.

  • Thomas D Guastavino

    Im confused. Is it not true all so called “normal” lab values are a statistic that has defined “normal” as plus or minus two standard deviations from the mean? Therefore some people are perfectly fine with their so called “critical value” Did the geniuses that thought up this “critical value red alert” system take this into account?

    • RenegadeRN

      Ha! Doubtful.

    • Paul

      By definition, 67% of values are within one SD of the mean, and 95% are within two SD. So it’s two. BUT not all lab value ranges are so calculated. For example, lipid “normals” are actually “desirables”, so way more than 5% will be outside the range. I mean, LDL < 100? Not in 95% of patients. And TSH, is 4.5 really normal? Many endocrinologists beg to differ. (I am not an endocrinologist, and I may be missing something here.)

      Clearly there are panic values (K of 6.9, hct of 4.5, etc). But God is in the details, and cannot be easily captured.

  • drjoekosterich

    The stupidity of government regulators and bureaucracy knows no bounds.

    • southerndoc1

      What the OP describes has nothing to do with government regulators and bureaucracy: it’s a voluntary certification process that, God only knows why, he freely decided to take part in.

      • drjoekosterich

        Good point but these checks like accreditation in Australia only happen because of government mandates.

  • RenegadeRN

    JCAHO makes me want to gouge my eyes and pull my hair! Everyone loses their damn minds for MONTHS before they show up, then after they leave- magically those new procedures, rules etc, just become less important and fade away…and the hospital PAYS thru the nose for the privilege. Gaah! What a scam.

    I think the ever increasing rules and regulations are not driven by concerns over improving patient care, but people being continually pressured to justify their job and worthiness of pay. So they make sh#% up for medical staff to deal with rather than patients.

    … Ok, off the soapbox …;-). …feel BP lowering already.

    • Thomas D Guastavino

      One of my basic rules of life is “Never trust anyone whose job it is to find fault with you” JCAHO inspectors will always find something wrong because if they don’t they will be accused by their superiors of not doing their job. For days the hospital staff, as you said, lost their minds trying to make everything perfect. My solution, purposely create one or two minor, non-patient safety related items for them to find. Then when they do, apologize and promise to have it fixed ASAP. Everyone goes away happy and lives to fight another day.

      • southerndoc1
        • Thomas D Guastavino

          I believe this may be satire but I would not be surprised if this was discussed during a JCAHO staff meeting

          • Lisa

            Um, may be satire?

      • RenegadeRN

        You are lucky to have that capability! The rest of is mere minions have to do as told. Ha ha.

  • fatherhash

    i truly wonder when(or rather if) physicians will ever be able to get back to just practicing medicine.

    not saying that these JC safety regulations/protocols are a bad idea(at least not bad intentioned). but still have to figure out ways for the doctors to be taken out of that red tape equation.

    • southerndoc1

      “I truly wonder when . . . physicians will ever be able to get back to just practicing medicine”
      As long as physicians like Dr. Pelzman continue to volunteer for this type of abuse, I’d say, oh, about the tenth of never.

  • Ladyimacbeth

    When I was a new employee at a previous hospital where I worked, I was told to hide in the gift shop until JCAHO left. They hadn’t had time to instruct me on all the things I was supposed to say, so they sent me to the gift shop. I’ve never spent so much time in a gift shop.

    • southerndoc1

      Hilarious!