We Don't Want You to Get Hurt

JCAHO and Press-Gainey and 'core measures', I submit, are the health care industry's version of protection rackets. I stand to be corrected so all you fans of JCAHO and Press-Gainey please do comment here and tell me why I'm all wrong, but here's the essence of my case.

A 'protection racket' is an age old scheme whereby individuals are strong-armed into paying money to crime syndicates or gangs to, ostensibly, avoid harm at the hands of "real criminals". Of course, the deal is that if you don't pay the protection money to the gang or syndicate then you are targetted and then, if you live, you have a real reason to pay the money, namely your broken arm or busted nose and the desire to, well, live.

Even though the kind of 'protection' we pay for with JCAHO and Press-Gainey has nothing to do with physical harm, doctors and hospitals have become dependent on getting good scores so they can advertise their "five star rating" or whatever, and individual ER groups often base bonus pay on a physician's Press-Gainey scores. These scores and the methods used to obtain them are NOT TRANSPARENT, and have the science of statistics behind them to be sure, but really, how much sense does it make to ask patients whether they received good care? First off, if you are answering the survey, you lived! Awesome. Secondly, it is an unfortunate axiom of the ER that if you are not really sick you are probably going to wait a long time and why the hell would you then want to fill out a survey telling someone how great your experience was?

How reliable is the data that is put into their equations to generate 'patient satisfaction scores'? Do they control for education level? Cultural bias? Whether the patient got free care or had to pay? And most importantly, do they actually ask if the patient, whatever the perception of their care, was treated appropriately from a medical perspective? No, they don't. Again, correct me if I'm wrong, and then explain to me and our readers, in terms we can understand, why Press-Gainey scores should be obtained to begin with. Why pay for information we can get anyway? For their 'lack of bias'? Well, PG is biased to keep their jobs so WTF?

It is not as if we are selling cars here. You may know jack shit about cars but you damn well pay for them when you buy one. In this context I understand, really, why being all about customer service will increase your business' success as you definitely want repeat customers. Also, while someone may lie to a car salesman about their income in order to get a better price, they have no other reasons to fabricate stuff outside the financial because the car salesman can not prescribe narcotics.

Next, and to tie the two together, I am unaware of any double blind placebo-controlled trial that shows that getting good JCAHO scores OR good Press-Gainey scores correlates with good patient outcomes and hence excellent medical care. Again, I may be wrong and stand to be corrected so please do tell me.

Etotheipi has already started in on these guys so please check out his previous post with the neat sharp sign.

Here's what happens in real hospitals with JCAHO and Press-Gainey. When JCAHO comes to town everyone goes into a tizzy. The most important things in the ER are, evidently, that we keep coffee and soda out of the nurses and doctor's areas. Coffee, soda, and food are still allowed in the patient's rooms though. Also, all the nurses and doctor's get handed little cards that we can read from in case the JCAHO flunky asks about what we would do with a blood spill on the floor. I want you all to walk in a straight line all the way to the lunchroom and everyone be quiet!

"Core measures" are an attempt to graph the ungraphable, and an attempt to put numbers on "quality care". They are also worthless. For instance, even after we knew that drawing routine blood cultures on patients with community acquired pneumonia DID NOT improve outcomes or change care in all but the sickest of the sick, JCAHO implemented this core measure and added $500 or so to all patient's bills by mandating this lab test. Art of medicine? Dear readers, ever hear of the New England Journal of Medicine? The Journal of Trauma? See, we already do this with rigor and thoroughness and JCAHO is, well, it's fucking JCAHO.

Press-Gainey gets us all worried fielding complaints from patients. The ER is "too noisy" or we "ignored them" and "spoke harshly" to them while they were here. This translates, often, into loss of income for us or even loss of our jobs. Only 1/3 of our "customers" pay for our services. Since most people who answer the surveys are already pissed off about their six hour wait guess what comes in on the survey? A lot of pissed-off patient complaints. Also, and again correct me if I'm wrong, admitted patient's are not surveyed so there is a preselection bias towards ER abusers.

To continue the analogy, while not knowing jack-shit about cars might make you prone to buying a bad car, outside of medicine no one knows an iota of jack-shit about why we do what we do and why we order the tests and studies we do in the ER. Getting that JCAHO star therefore means lots of money to our bosses. Protection racket.

News flash! Even though you are a nice person and are sure you are not having a heart attack I have to look. You came to me with chest pain, I've never seen you before, I have no records on you, and I can not, without committing malpractice, just write you a work note and tell with my hugely developed clinical acumen and Xray vision that your "indigestion" is "nothing serious" and "not your heart".

But here's a kicker, guess what we do after a bad patient outcome or with problems in how we deliver excellent care in the ER? We ask each other and do research and go to conferences and see what the pointy-headed academics are doing. We never say, "Hmm, why not ask JCAHO or Press-Gainey about this?"

JCAHO and Press-Gainey are parasites. They are solutions in search of a problem. With rare exception none of the JCAHO or Press-Gainey folks are practicing physicians. These companies have grown eighteen heads and can not be killed. They are feasting off the detritus of the piles of money that get shuffled around in the medicine game. Unfortunately, hospital CEOs and ER group directors have signed on because, I guess, having some information (however shitty it might be), or some way to put intangibles on a graph (and to show the upward trend), is worth something to someone.

Finally, it's nice to have a bullet in your gun when coming to the table to negotiate a contract with your ER group or when you want to ride herd on your nurses. Press-Gainey and JCAHO provide the bullets. Then, when they are fired, just like the Chinese, those who are executed have to pay for the bullet.