Monday, May 15, 2006

The JCAHO Shakedown

JCAHO (commonly referred to as 'JAY-CO') is an onganization that has us by the short hairs. It is a prime example of good intentions evolving into micromanagement and unintended consequences. I could take the time to educate myself about the organization that has it's nose in every hospital nook and cranny across the fruited plain but I'm really not interested because I can't change things and have to live for now with the JCAHO reality which is this.

JCAHO provides accreditations to hospitals that allow them to continue to operate with a ''clean bill of health''. Without JCAHO accreditation your hospital is a pariah and funding and reimbursement dry up until you toe the line. I'm sure they do some good work but the following are examples of the absurdity that we deal with everyday in the Emergency Deparmtment.

JCAHO has established 'core measures' for all emergency departments, one of which is that we must draw blood cultures on all pneumonia patients. Never mind that the literature does not supoprt this as helpful in standard cases of pneumonia, never mind that blood cultures add hundreds of dollars to patient's bills, we have to do them because if we don't our 'core measures' score will not be good and we can't advertise complete compliance with the JCAHO standard.

If I am Joe Shmo and have never heard of JCAHO and don't read the New England Journal of Medicine then I damn well want the hospital I go to to be JCAHO compliant. Why wouldn't I? They know, don't they? Well, no.

JCAHO progressively has taken decision making away from doctors and nurses and made much of what we do redundant and 'by the book'... the blood culture example being just one of many. Are the rule makers at JCAHO doctors? I don't know, but I do know that most physicians who work for JCAHO no longer practice medicine themselves. Now here's the real shit.

Because of JCAHO we can not have food in the ED. We have to leave the ED to eat. Probably, I think, the hygeinic concerns might be outweighed a little bit by having staff out of the ED for even short periods of time. Also, I now have to push certain drugs myself. The nurse is not allowed to even if I order it. The ridiculous result is that I have to futz around with IV lines and have the nurse show me where and how to push these medicines. Does this make sense? A nurse, specifically trained to start IV's, do assessments, and push medicines is suddenly restricted so that I, with very little training in the above, have to stand with a nurse at my side and push the plunger at the nurse's direction.

I hate JCAHO.


  1. The crucial sentence was that the doctors at JCAHO, if they are doctors, do no longer practice medicine. Say it louder, so that everybody can hear it.
    And, you know what? It will get worse in the future.

  2. Replace JCAHO with AACSB (accredits colleges of business) and it is the exact same situation. Luckily there are no lives at immediate risk.
    On a separate note, is there some way I can get you guys to give me real stories about state professional scope-of-practice rules that are blatently ridiculous (for lack of a better word)? I'm an economist writing about state licensing of medical professionals (scope-of-practice for physicians and non-physician clinicians) and need some real world examples. Or, if you think state scope-of-practice rules are the best thing since sliced bread, I'd like to know as well. I'm at, I'm counting on you ;) although the fact that your favorite music is ABBA concerns me.

  3. shirley,
    i would be happy to help but quite frankly you will need to inform me about what these rules are. i have a feeling you are talking about rules peculiar to each state which define the scope of a particular physician's practice... procedures, treatments and whatnot.

    i have never run into a problem with these because each hospital has a credentialing department that has created it's own scope-of-practice paperwork, usually about 60 pages, which i never read but sign only, and i check boxes in procedures for which i am seeking credentialing and am qualified, then, weeks later, my priveleges are granted.

    i'm sure the credentialing department makes sure they are in compliance with the laws.

    as you probably know each state requires licensing for physicians. there is no national license to practice medicine. i have, so far, been licensed to practice in four states and it's all similar painful process to get licensed, and a similar painful process to get credentialled though i hear that texas and california have the worst and most onerous physician licensing requirements.

    i will try to answer your question more fully but need more info.

  4. I'm thinking of examples of either intra- or interstate inefficiencies. Intrastate inefficiencies could include, say, specific tasks that lie outside NPs' SOP, but that many NPs are perfectly well-qualified to perform (i.e., why should an NP have to go through medical school just to do X?). Interstate inefficiencies could include, say, an NP who could perform X in his licensing state, but who cannot perform X in the state where he now practices. Also, I've read that job ads will state that they are looking for a "PA or NP." If specific training is as important to patient care as advocates say it is, it seems any particular position would require one or the other, not either.
    Don't know if you know, but the AMA has set up SOPP to monitor efforts of non-physician groups to secure enhanced SOP in every state. SOPP:

  5. dear shirley, god bless ya, i care so little for acronyms that i nearly hit my head on the table in the middle of a snore.

    i think your man on this might be panda bear, he's linked on my site. he has posted on midlevel scope of practice before and has some very strong opinions as do i... starting to wake up now.

    the whole PA v. NP thing mystifies me. as a whole i much prefer to work with PAs though i have one outstanding NP that works for me. my explanation is that NPs are nurses first and are taught by nurses and NPs are steeped in the culture of nursing and nurses tend not to be great independent problem solvers, again, not a rule, but an observation.

    PAs get their training from docotrs and other PAs, they are physician-culture based, and i just think they are better in the ER than NPs in general and more comfortable making decisions.

    it's hard to get in to medical school, not as hard to get into nursing school or PA school. some nurses would do great in medical school, most wouldn't. anyone who graduates from an american medical school would eat nursing school for lunch. midlevels are midlevels for a good reason and while i do believe that individual midlevels should, after, i don't know, ten years of practice, be able to expand their scope of practice within their chosen specialty, i don't think they should ever get an MD by their name, because they are not doctors and did not absorb the incredibly broad knowledge base that we did.

    after ten years i don't remember much about biochemistry, it's true, but now we are discussing economics more than medicine as you will have a hard time getting anyone to go to medical school if you can back-door it without the risk by becoming a PA or NP.

    as to why PAs and NPs can't do certain things here and there and whether they should be able to i truly don't care. what i care about is if they are good or not because it's my license on the line and my malpractice they are operating under and mistakes they make are my mistakes by respondeat superior. if they want to open up clinics that are free standing and are trying to change the law to do that i'm not going to stop them.

    without making light of your question and without being literal in this analogy, a very wise surgeon once told me, "you can teach a monkey how to operate, you just can't teach him when not to."

  6. I take issue with the allegation that getting into PA school is easier than getting into medical school. Having gone through the application process I would claim, if not the reverse, then that it is at least equally as difficult. For one reason, there are only around 7000 (if I’m being generous) PAs graduating every year whereas there are more than twice that many medical school graduates. Also, medical schools’ pre-requisites are relatively consistent whereas to apply to more than one PA program requires that a candidate have a vast number of courses already completed. In addition to all the coursework, PA programs are intent on service work and direct patient contact experiences (~2000 hrs on average). Application review board members will admit: PA programs are looking for students who could successfully apply to medical school; they want PA school to be a choice over medical school for applicants. Programs don’t offer themselves as consolation prizes to those who really wanted to go to medical school.

    I’m not suggesting that on the job being a physician isn’t harder or more demanding and certainly physicians do, as you mention, bear the responsibility for PAs'/nurses' which is a heavy burden. However, it is a burden that does come with some consolation prizes: physicians get to be the top dogs in the nurse-PA-physician hierarchy. And as the research shows: on average, the people who have the highest job satisfaction and least work-related interpersonal stress are those who have the most autonomy.

  7. Dear 911doc--

    Just so you know, we "JCAHO" survey coordinators (those pesky people in your ED's--who are NEVER doctors--who poke around doing tracers to see if you are complying with the latest iteration of the 'standards') hate JCAHO.

    We hate them because they don't even practice medicine anymore. We hate them because their surveyors have zero objectivity. We hate them, especially, because they are now citing hospitals for continuing to reference them in their policies as "JCAHO", since they changed their acronym in 2007 to "TJC".

    Surveys suck. They are unnecessarily stressful and entirely unhelpful. Surveys force hospitals to 'fix' things that are observed in one or two or three days, that don't address culture, Leadership or accountability. It's about pretty policy books, documentation and well-rehearsed staff.

    I work in a small psychiatric hospital in Texas. Your blog is a recent find, and it makes me laugh every day. Thanks for being the cynical folks you are!

  8. Love, love, love the comment about graduates of any American medical school eating nursing school for lunch! I work as an ED RN at a Level I teaching facility and I wonder how a majority of these said graduates learned to tie their own shoes, much less graduate from med school. Sounds like someone is beginning to develop quite the ego! You must have forgotten the nurses who saved your butt (and its wide expanse of knowledge) as a med student or resident. Don't you know they take us all aside in nursing school and teach us how to prevent you god-like creatures from killing OUR innocent patients? I agree that what RN's learn in nursing school is a much more focused (ok, yes, smaller) body of knowledge than one would receive in med school, but just because we learn less does not mean we are less capable of learning (great monkey analogy). While incredibly intelligent, I doubt at least half of the med students, residents and even seasoned attendings I meet would last very long in nursing would require the ability and willingness to remove one's self from the proverbial pedestal and interact with humanity at the most basic levels on a daily basis. Some people got it and some people don't. I could go on and on about the art of nurturing and caring, blah, blah, blah but I assume you are already rolling your eyes.

    I agree vast differences exist between medical and nursing models in regards to the delivery of healthcare and I acknowledge that both physicians and the public-at-large both respect and feel most comfortable with the traditional, medical model. Thus, as I pursue my goal to become a mid-level practitioner, I have chosen to become a PA. But I believe my background in nursing will make me a much stronger, more well-rounded provider of healthcare.

    In essence, quit denigrating nurses as mindless monkeys and be grateful you have someone to assist you with your...let’s call them you can remain safely positioned as a higher being above "us simple folk".

    Examine your sentence " with PAs though I have one outstanding NP that works for me". Interesting. And one more thing- what horrible, forsaken place do you work at where "your nurses" don't have the ability to independently problem solve...that must be absolutely terrifying, I would fire them all.

    P.S. No, you can't have my chair and you can go get your own damn cup of coffee...but get me one while you’re up!

  9. first of all, anonymous,
    i can't figure out why your name is so popular all of a sudden. secondly, if you work at an academic center then you have not seen the problem. third, i'm not getting you coffee. if you can show me that the nursing curriculum has not changed from patient care to chart care then i will take it all back. if you can show me the higher standards that exist today to both get into and then graduate from nursing school then i'll shut my mouth. if you can show me newbie grads from nursing school that respond to patient complaints with something other than 'it's in the chart' then i'll take it back. toodles,