After COVID-19, can we really stomach the minutiae that comes with the next Joint Commission review?


I’ve always been fascinated with dystopian novels and zombie movies.  When the apocalypse comes, we stop sweating the small stuff.  Important tasks like sculpting our abs or finding the perfect area rug suddenly take a back seat to the new primary directive: survival. Nothing else matters.

Healthcare workers have taken a similar survival first approach to COVID.  We’ve put aside our tiny tragedies and banded together to save our communities.  It’s been exhausting, heartbreaking, life-threatening work. We’ve been called heroes, but there are no starring roles, no pithy one-liners.  It’s been all too real and all too awful.

And yet, there have been silver linings.  I’ve never seen better teamwork between physicians, nurses, and leaders.  It probably helps that we’re all wearing the same PPE uniform – looking alike sadly is no small thing when it comes to treating each other well – but for the moment, our hierarchies are in hibernation. Telemedicine has finally gone prime time, and with it, patients can receive efficient care without driving to a distant clinic and sitting for hours in a waiting room.  We’ve been forced to have difficult conversations about critical resources, concluding what we’ve really known all along; we can’t offer everything to everybody all the time.  But perhaps the biggest win is that we’ve nearly eliminated non-essential work.  As one colleague put it, the bullshit is gone.

It’s time I make a disclosure.  I’m not just a hospitalist; I’m also an administrator.  I’m that guy who badgers you about your admission orders, length of stay, and overflowing EPIC inbox.  Curse me if you like, but I’m also the person that solves impossible discharges, barters with skilled nursing facilities, and interfaces with the myriad of community agencies that keep our patients safe at home. I’m an interpreter of and occasional expert on a tangled world of payment systems and regulatory madness.  It’s a role I took on two years ago, and it’s honestly been a gift. But I’d be lying if I called everything I do essential.

No topic raises more ire than documentation.  We all agree that documentation is necessary, but we disagree wildly on the details.  Words that satisfy the clinician don’t always meet professional billing standards or capture golden rings like major comorbid conditions.  It’s my job to preach the why, namely that using clunky phrases like acute blood loss anemia or severe protein-calorie malnutrition paint a more accurate clinical picture, which makes our hospital’s quality metrics pop and ensures appropriate reimbursement for the care we provide.  These statements are true and important, but they don’t always resonate with the front line.   Usually, we just agree that the whole thing is a crazy-making requirement of our job, dictated to us by CMS, Vizient, and other Big Brothers.  Every job from the proprietor to professional athlete has its headaches.  That’s not especially inspiring, but it’s genuine, and sometimes it helps.

2020 was the year we planned to launch a new documentation software system, something that would better identify coding opportunities and propel us into our cohort’s top ten.  The upgrade included a requirement to re-educate busy clinicians on the finer points of note writing, which only sounds terrible because it is.  The truth is, I dreaded it too.  I believe in the why but couldn’t stand the thought of pulling my colleagues out of surely more important duties only so they could fiddle with their mobile devices and shoot us glares of disdain.  The sessions were scheduled for May, but then COVID came.   We quickly realized that the logistics were impossible, and the subject matter was tone-deaf.  When the meetings were canceled, I wasn’t just relieved.  I was overjoyed.

The crisis, in contrast, has been a calling.  We cared for the homeless and the nursing homes, built field hospitals and recovery centers, provided transportation for our patients, protection for our workforce, and so much more.  It’s all been necessary.  It has all been meaningful.

Like the rest of the world, we now sit in an odd place.  We’re poking our heads out of the bunker, scanning the battlefield.  The virus endures, and with every encounter, we continue to put our lives on the line.  Eventually, we will inch forward, seeking a new normal where we can still cure disease, manage chronic illness, and pay the bills with knee replacements and valve repairs.

It’s also an opportunity to reshape our reality, a golden moment to question the bullshit.  I remain committed to the mission and am sensible enough to know that requires a margin, but let’s ask ourselves:  do we want a healthcare system that places this much emphasis on counting midnights, mining hierarchical condition categories, and regurgitating complete 10-point review of systems that are otherwise negative?  Are we resigned to doing peer-to-peer calls and prior authorizations in between cycles of donning and doffing?  Can we really stomach the minutiae that comes with our next Joint Commission review?  These are not inherently meaningful pursuits.  They’re only as necessary as we choose to make them.

I leafed through one of my favorite books recently, Stephen King’s The Stand.  It remains brilliant, but I have no desire to read it again.  We’re already living in a dystopian novel.  The next time I go into a virtual bookstore, I’m headed down a new aisle.  Let’s call it renewal.

Steve M. Grant is a hospitalist.

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