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

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