4 problems with the Joint Commission

I’m passionate about patient safety. In no small part because I was raised to be. My mom has a lot of letters behind her name (RN, BSN, MSN), and she’s dedicated her career to the field.

Before I was accepted into medical school, I knew about “six sigma,” the “Swiss cheese model” and root-cause analysis. I’d been taught about creating a culture of safety and the example of the airline industry. I’d also heard of the Joint Commission. Much of my mom’s job was making sure that the famous hospital where she worked was compliant with their safety standards.

After earning an MD, I began my career and noticed whenever the Joint Commission came up around colleagues (MDs, PAs, RNs) there would be a lot of eye rolls. I didn’t understand it. Why would those who dedicate their lives to patient care resent an organization dedicated to patient safety? The most talented critical care physician I’ve ever worked with shared his flat-out disdain for the organization as our team scarfed down Thai food at 9 p.m. on a Saturday shift. I noticed another provider I greatly respect glaring at a hospital administrator as she went over how crucial charting in the EMR is (“There’s a Joint Commission visit coming up!”). To get an idea of how some health care providers feel about the Joint Commission just read this satirical article.

Over time, I’ve become disillusioned with the Joint Commision as well. However, I care about patient safety enough to recognize that, despite their flaws, they still have an immense capacity for good. From that vantage point here are 4 things I wish they knew:

1. Nights and weekends count. When the Joint Commission reviews a hospital, the most critical component is an actual visit where members of the organization go to the hospital for around five days and observe the care provided firsthand. This sounds great— until you learn that their visit hours are about 8:30 a.m. – 5 p.m. Monday through Friday. Isn’t that odd? It’s hard for me to believe an organization truly cares about patient safety when none of their crucial observations are done during some of the most critical hours. Early mornings are when residents round. Evenings are when handoffs take place. Nights are when provider fatigue sets in. Weekends are when limited staffing causes challenges. These are the times that pose the most significant patient safety challenges. If you want us to view you as patient safety advocates rather than bureaucrats, ditch your comfortable hours and come when it’s crucial. We’re at the hospital 24 hours a day, 365 days a year. We’re waiting for you.

2. Documentation isn’t patient care. Aside from their visits, the Joint Commission absolutely loves to review documentation in the electronic medical record (this is even their excuse for not coming in during inconvenient hours; they “view the records” from “off” hours instead). But the record doesn’t always paint the most accurate picture. On one overnight shift, I was so concerned about a patient that I visited her bedside seven times. I didn’t write any notes in the EMR because it wasn’t required or practical. I was providing diligent care, and that was what mattered. On one weekend morning, I was required to see such an absurd number of patients before 7 a.m. (I won’t even divulge the number because it would scare people) that I was forced to work at lightning speed. A three-minute encounter with a patient that morning produced a progress note so lovely that it would have you believe I did a great job. It is crucial for the Joint Commission to realize that the EMR is like a painting, not a photograph. Not every detail is captured, and what is captured doesn’t always have a “life-like” quality.

3. Regulations don’t always rule. After the visit and EMR review is complete, the Joint Commission determines the patient safety problems then it’s off to regulation race. Hospitals receive ratings, target metrics are determined, and rules are made. Some of this is incredibly necessary. But a lot of it is more meaningful in theory than in practice. What is the easiest way to solve a patient safety problem? Require health care providers to document something or regulate something. I wish they understood that every minute spent documenting or dealing with regulations is a minute spent not caring for patients. The personalities who enter health care are often diligent people who care very much about requirements.

Consider a surgical nurse trying to document an instrument and sponge count (to ensure nothing is left inside the patient) at the same time the anesthesiology resident says that the patient has lost blood and needs labs sent to determine if transfusion is necessary. Despite the fact that the labs are unquestionably more important (patient care) it is the count that is a responsibility (a documentation regulation). This is a true story, and the nurse in question put off the crucial labs until her count was complete. These types of instances occur across our country on a daily basis. Despite the fact that our hearts are in the right place, we tend to fulfill requirements and regulations (necessity) before focusing on patient care (desire).

4. You are not a health care provider. I come at my last point gingerly; please remember my mother is among your ranks. You fulfill an important role and deserve every credential you’ve earned. Your motives are pure. Your knowledge base stands. Your current role has great value. You are still a nurse or a physician and a valuable contributor to health care. But you need to humbly realize that you are no longer a health care provider. You no longer wake up to work 12-hour (and up to 30-hour) shifts in the dirty trenches of sick patients bedsides. You are no longer responsible for the endless charting, caring, worrying and monitoring that comes with it. The longer you’ve been away, the greater the chasm. At some point, you chose to leave the patient’s bedside. I don’t fault you for it. But I do expect you to acknowledge it. You’re not “one of us” anymore, and that makes it even more important to listen to us.

The author is an anonymous physician.

Image credit: Shutterstock.com

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