Wednesday, April 09, 2008

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.


  1. I'm curious about something: Why does your average inner-city trauma center give a &$&# about getting a five star rating? You guys have talked a lot about your typical patient population. Something like: 10% critically ill/injured. Those guys aren't shopping around for care, they're going straight to the closest place that can help them. 50% using the ED instead of primary care because it's free. Those guys also don't care -- free medical care is free medical care, never mind its rating. 10% looking for drugs. Those guys definitely don't care about ratings, in fact the lower the better.

    So if this is right, your "customers", for the most part, don't care about JCAHO/Press-Gainey ratings. So why do the providers care? I'm serious -- at least for major, maybe non-profit, large urban trauma centers, why don't the hospitals turn around and tell JCAHO where they can stick it?

  2. emmef,
    great question. i think the answer is twofold. first, some hospitals do tell jcaho to stick it. i have heard that mayo in MN told them to fuck off. i hope that's right and not a rumor. secondly, in order to make money to pay for those who don't pay i guess the 'five star' ratings matter.

  3. UGH! That's just more depressing. I have no clue how to help the problem either. How do you dislodge deeply entrenched beaurocrats from their positions of power? With a crowbar?

    If I ever got a survey, I always threw it away because I only felt like filling them out when I was pissed off about something. Like when I had a pediatric ER, I'm assuming resident, eyeball my 3 day old daughter and tell me that her bilirubin was probably a 12.8 or so. Being a former labbie, I debated mocking him to his face, but then just said, "But you WILL test it anyway, won't you." Because I'm polite like that. It ended up being 16.9, so they admitted. We brought her in because she quit breathing while I was nursing her, and turned blue as a blueberry.

    Ugh, sorry for the randomness. THat's the only time I've ever been pissed at the ER.

    Press Ganey sucks and so does JHACO, and I think your arguments are completely spot on. Your scores and paychecks should ABSOLUTELY be based on outcomes. And even then, you can't save everyone, nor are you perfect. My lab director used to say that even the most proficient person will screw up 1 time out of 1000. Outliers happen.

    The measure of blowing sunshine up someone's ass isn't exactly correlated to health outcomes now is it?

  4. *sigh* why can't you/people like you be in charge?!

    none of this bodes well for those of us looking for a future in EM...

  5. So, I've been lurking on medical blogs, and far as I can tell, you are all full of shit. Jack-shit, bullshit, horseshit, farts... there is more to medicine than the back end, people!!! Ever heard of a stethoscope?

  6. I have taken patients via ambulance to the Mayo clinic. While I, as a paramedic, am picking through the gutter in terms of how other medical people view me, am not a patient, I have realized that hospitals which treat us like shit tend to treat their patients and coworkers like fucking slime.

    When you transfer into Mayo, at least St. Mary's in Rochester, which really is the mayo in the Mayo, there's a lovely charge nurse in black scrubs standing by the door greeting each ambulance patient. You are provided with a greeting, a room assignment or disposition, and an escort to the patient's room if its in a far flung area. It is by far one of the most wonderful experiences. From the second a patient walks in the door, people act like they know what the fuck is going on. They take care of shit and keep things moving. Things are ready. Beds are in place. IV pumps are set up with the tubing primed. It's not some mickey mouse bullshit where you stand around.

    That is what it's like to have your shit together.

    But, they still use Press Ganey. And they're ranked quite highly.

    Theres another major hospital I go to routinely. Big academic hospital. Level 1 trauma center, famous school affiliation. In a big city. They're the biggest bunch of cunts in the world. Absolute fucking whores. I wouldn't take a fucking dead gold fish there to be flushed down the toilet, let alone an actual human being. When I find some gorked, pissed covered, shit stained, toothless, violent, drunk dirtball of a patient, the kind who spits HIV infected blood on the floor, I always find a way to take them to this particular hospital. You know, because they're so academic and have wonderful services for this down and out fellow.

    Yeah that shitbag place also ranked super dooper high on the Press Ganey scores. So I haven't really figured out what exactly is being measured. People hate going to this hospital. I have yet to meet a patient who actually wants to go to this ER. Yet, they claim these wonderful scores on par with the Mayo.

  7. richter,
    please explain. are you yelling at us or at the people we are yelling at?

  8. Both. (I like to yell.) And then when I get tired of yelling, I'll talk to both of you. sweet nothings apparently - because apparently I'm an ignorant, uneducated, asinine(!), etc. etc., you get the idea, with nothing much worth saying. You may as well ban me from your comments now - save us both time and trouble.

  9. hmm,
    you don't seem to be ignorant or assinine but i'm afraid i still don't get it. we don't ban anybody from our posts. come by anytime.

  10. I think we all should just say No to Jcaho. I would love for my hospital to tell them to take a flying leap. I think the DPH should make surprise visits. I have never seen Jcaho make surprise visits. The Jcaho folks cannot stay up that late.

  11. One of the joys of working all overnights is the special feeling I get when I hear that JCAHO "will be coming by the ED...tomorrow morning."

    We spend all night giggling and cheering, knowing that we're spared the inspectors yet again, because they don't get up early (or stay up that late) to play with the night owls.

  12. More reason for a doctors union. You don't see any JCAHO going into the Ford factory to make sure all the lug nuts are tightened. If they tried they'd get a monkey wrench upside the head from Guido or Tommy and 50 pounds of dynamite in the trunk.

  13. Excellent post.

    I think the idea of a randomized double-blind clinical trial to measure the effectiveness of JCAHO and P-G on outcomes is brilliant. I would bet ALOT of money that it doesn't make a micron of difference.

    I can only see downside to the function of a hospital when the efforts of those in charge are focused on jumping through hoops and manipulating patient perception.

    If we ACTUALLY think that a hotel-like experience is the ideal for a hospital then we should hire a Hilton executive (not Paris) to run the place. Let's give the patients mints on their pillows and a personal concierge. My guess is that the PG scores would be through the roof. I would also guess that more people would die or get marginal care because WE ARE CONCENTRATING ON THE WRONG THING!!!

  14. Richter,
    I had a kid in a UC trauma ward for weeks last year with horrifying pelvic injuries and I think I know why they get good scores. I'd bet that 9/10 of the patients treated don't return surveys, as they're busy setting up their next meth lab. The ones who do, like me, are grateful that their kid was somehow patched up and saved. I'm sorry you were treated like crap--I didn't even see that entrance to the facility, as my kid was coptered in.
    It was filthy and chaotic (I mopped the floor myself), but the medical care was excellent, if a bit excessive. My son said, "Jeez, there are, like, hundreds of medical students and doctors who want to see my junk". We subsequently were sent to another private, highly rated hospital, which was very clean, but the medical care was practically actionable, and the kid was constantly discharged and returned via ER. Cleanliness and politeness are secondary to good medical care, and I'd take the filthy UC hospital anytime.

  15. "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."

    So true, 911Doc. Oh, and don't forget the importance of not using the "do not use abbreviations". Such stupidity is hilarious.

  16. When mobsters run their protection racket, part of their strategy is to break the bones of anyone who rats them to the police or speaks out against them. In this case, there are no police to ask for help because it IS the police who are running the racket. You are doing the only thing you can and that is to try and educate the voting public. Thank God for anonymous sites like this. Can you imagine the JCAHO/PG folks reading these great whistleblowing blogs, feeling threatened about losing their power and targeting the doctors who write them for an upcoming "extra diligent" inspection visit?

  17. Devorrah: I feel your sympathy, and I appreciate it. Also, I hope your kid is doing better. And, I'll take your hint and look for a chaotic and filthy (UC) hospital. (What is a UC hospital? Is that a specific type of hospital that you are also recommending? TIA.)

  18. I could not agree with you more. Everywhere else in medicine we are being pummeled with the "evidence based medicine" mantra --- why not with JCAHO mandates? Is there any data that a 52 point "time out" check list in the OR does anything other than cause frustration, or that keeping coffee cups away from ED physicians and nurses is good for patients? In a word, no. I think it is high time hospitals across the country started chanting "Hell, no, we won't JCAHO."

  19. JCAHO...

    Must get coffee cups out of nurses station and stop abbreviating morphine as MSO4 (I think I'll switch to MoSO4!).. blood pressure rising.. homicidal urges building..


  20. Aggravated docsurg: At this point, I'd like to see some evidence that you would be able to recognize/and/or/evaluate a clinical study. I think it's fucking scary that people who are obviously mathematical and statistical illiterates keep calling for evidence based medicine. I say that you would not know good statistics if you met any in a dark alley. You wouldn't know good statistics from Adam. Richter is aggravated this morning.

  21. To Richter:
    I am quite sure that most every medical professional posting here can and do not only recognize and evaluate a clinical study, they also use the results in their daily practice. And that, my friend, is exactly the point. There is NO study to evaluate whether or not JCAHO or PG are doing any good at all!! As a matter of fact, I believe with all my soul, as a practicing Peds ICU RN, that they do nothing of benefit. In actual fact, I think you would find, if you could ever get a study of their effectiveness funded, that they actually do more harm.

    Overall, I couldn't agree more with this post. I wonder what it does to the PG scores when you are asked the same questions at least 4 times in the space of an hour. Let's see: triage fills out their questionnaire, then the ER doc asks many of the same information, then you come to the ICU and we, the nurses, have to ask everything again, then the ICU doc asks many of the same things...after that, if you also need a specialist consult, you get asked everything yet again. Why do you get asked all these things over and over again? Because JCAHO says we have to!! We can't trust our coworkers, it seems.

    One last point about matter the numbers, they can be used to prove your point..any matter what your point might be.

  22. One last thing, if anyone knows, FOR A FACT, of any hospitals that have kicked JCAHO out on their ass, I would love to know about it. I hope to put together a list of those hospitals and see whos who. I heard a rumor sometime back that both Hopkins and Vanderbilt have kicked them out, but have been unable to confirm it. I think a list of this sort could be invaluable for any of us trying to convince our employers to do the same.

  23. So, it's put up or shut up time now. I've got a friend who's an epidemiological statistician and I'm going to try to convince her to do a comparison between P/G scores and reality. However, I'm a Ph.D., not an M.D., so I need help with what reality is. What objective measures of patient care should be collected? How would you identify the deadwood and the 007s? How do you tell the difference between a bad ER and one that's being crapflooded with patients that are beyond the scope of emergency medicine?

  24. Ya'll know that Richter only came over here because he/she just got banned for awesome trollness over at Pandabear's right?

    How's High School Richter?

  25. richter huh,
    was nice to him last night then he goes on some psychotic rant that makes about as much sense as a psychotic rant would make then mentions that he has a hairdresser. hmm. a hairdresser. he may be the first banned from our blog too. richter, straighten up and fly right or be banned you asshole.

  26. Richter,
    if you're such a statisctical expert tell everyone how you calculate a pitchers earned run average. Hint, its a brief one line equation but your hairdresser probably won't know it. No fair looking it up.

  27. it seems like there's a lot of agreement among health care providers concerning this issue, and a lot of evidence that the joint commission and p-g scores are doing more harm than

    what's to be done about this?

    Someone said something about a "doctors union", but the AMA seems like it already has a lot of clout (too much, I'd argue), and it seems to me that change would have to come from the lobbying priorities of the professional organizations that health care providers belong to.

    Additionally, as diluted and unreliable as the peer-review circuit has become, publishing research either contradicting current practices or supporting alternatives might help?

    The thing is, it's going to take more than just one segment of the health care delivery sector to undo this bureaucratic nonsense.

    A "legal" option might be lobbying to revoke the salient corporation's "corporate personhood", effectively dissolving the offending organizations directly.

  28. Oh 911doc, please, please don't ban Richter! I think that he is just so cute when he gets all in a tizzy!

    Re: "you would not know good statistics if you met any in a dark alley;" well, of course not! Dark alleys are too dark to see your Texas Instrument calculator screen while you are verifying the accuracy of the researcher's chi square calculations. Anyone knows that.

    I was a charge nurse during a hospitals initial JCAH accredidation. It was like being a bit player in a bad situation comedy. The floors did get mopped more frequently, which was nice, but otherwise it was a matter of stroking the egos of the inspectors and trying to keep a straight face while answering their questions (absolutly none of which had anything to do with patient care). We did as we were told, got our accredidation, and breathed a sigh of relief when we could stop wasting time and return to the care of our patients.

    I do miss those nice floors, however.

    (Note to Richter, we now have treatments for Tourette's Syndrome. There is no cure, at least not yet, but there is treatment, and hope!)

  29. Maybe Richter is just "The Dawn" reincarnated?

    oooooooooo *insert Twilight Zone music*

  30. what kind and compassionate people you all are, to feed the trolls as you do! hehe

  31. Amy: high school is busy and stressful right now.
    Countryrat: I'm flattered that you think I'm cute, when I'm in a tizzy. (Which is most of the time.)
    911doc: no fair banning me from my first comments post. That's not fair. So, I'll try to behave. (straiten up and fly right? could you clarify that????)
    Everybody: I don't know that much about statistics. I'm not that educated, yet. (I'm just thinking about being pre-med, maybe.) I'm just trying to say that it's pathetic how little all of you know about statistics. that's all.

  32. Richter,
    UC means Univ. of California, (at Davis and San Francisco, both pretty close), and my kid is doing great. Now quit running with scissors please and play nice. Oh yeah, school is out for the day...

  33. Our Hosp does not belong to JACHO but they sure are uptight about those freaking "Press Gany". The we do not give a crap if the pt is lying , you have to because they would never lie, whine or say so otherwise."

  34. This comment has been removed by the author.

  35. Yay, Trolls!

    *sniff* I kinda miss The Dawn.....

  36. Richter:

    "I'm just trying to say that it's pathetic how little all of you know about statistics. that's all."

    If you can't tell statistics from your...ahem...eyebrow, how on earth will you be able to determine if docs know statistics or not? Stats is a pre-req for med school.

    Some of these doc dudes are pretty mathy. And geeky. That's all I'm sayin. Etotheipi and S Cat and p value and all.

  37. E.R.A.(Earned Run Average, not that pinko/commie Equal Rights Ammendment)= (Earned Runs Allowed/Innings Pitched) x 9.
    Major League Average is around 4.5.

  38. How DO you put a metric on Emergency Department? Clearly one would be if you left in better shape (I'm not dead yet!) than when you came in. Speaking as one who has recently visited the ED with an injured loved one, I found that a little simple politeness really goes a long way and we were treated with a lot of respect and with the necessary attention given the severity of the injury.

  39. Devorahh: "I'll be your friend" - thanks, that is bighearted of you.
    But as for the rest of your advice:
    "First, no name calling.
    Second, you can express an opinion without flaming out of every orifice.
    Just curb your enthusiasm a bit"
    I don't think I can. I just don't think I can. Not even the curb my enthusiasm part. Not even a little bit.

  40. richter,

    "Everybody: I don't know that much about statistics. I'm not that educated, yet. (I'm just thinking about being pre-med, maybe.) I'm just trying to say that it's pathetic how little all of you know about statistics. that's all."

    first, take logic 101.

    secondly, and quite seriously, are you on medication? who exactly are you angry at?

    come here with an opinion, defend it with logic, and we can have a discussion. otherwise, go get your own blog and quit bothering people with your nonsensical ramblings.

  41. OOoohhhh! I just got called with one of those surveys, about my son's procdure he had 2 weeks ago. They asked me all sorts of questions like:

    Did the surgeon do anything to make you think he didn't know what he was doing?

    Were you afriad at any time that they might screw things up?

    Did you hear any staff bad mouth any other staff?

    And the usual was the joint clean, etc?

    And this one was strange: Was your son given any medications that he hadn't had before?

    Now how would I know that? I did recieve an itemized list today of the meds and their costs today, but I have no clue as to what they doped him up with his last surgery besides demerol because he growled at the nurses.

    If only the crackheads just knew that they needed to growl at the nurses. Course they don't want demerol do they?

    FYI: It wasn't Press-Ganey, I asked. It was something and Jansen.

  42. Richter,
    Actually, I do have a big heart, and you don't even have common courtesy. Please go find another outlet for your out-of-control anger, and don't expect anybody at hospitals or blogs to be nice to you when you're spewing malice every time you open your mouth or browser.

  43. You can search online on at to see which hospitals are accredited. Mayo is not only accredited, it has the "Gold Seal of Approval." SIGH

  44. "I'm just trying to say that it's pathetic how little all of you know about statistics. that's all."

    Oh, my dear, young friend, you do not have any idea what we know, or where we have been, or what we have done to earn the privilege of membership in our various professions.

    Thinking about medical school, eh? Good for you! That is a noble ambition, and I wish you well. Maybe, in a few years, you will have experienced what it means to be responsible for the life of a human being who is depending on you to help them. On that day, you will, I am sure, have many interesting and informed insights to share with us. I would like to hear from you again, if that day should ever come.

    Very best wishes,


  45. I'd like to go on record saying that it's much more fun when you guys dissect the JCAHO charlie foxtrot than watching the fairly thorough gangrape of whoever the fuck "richter" is. It's fun, he's annoying, and it feels good, I know, but JCAHO's a little more....uh......relevant.

  46. "JCAHO charlie foxtrot"

    OMG. That's funny. It's like a secret code...and this time I GET IT!!!

    Yes I am slow. I speak toddler all day.

  47. Devorrah- Nope, but if we don't stick with some semblance of the topic, eventually somebody's gonna go whip us all into a mad hockey frenzy, and we'll forget all about hospitals for a while. Outside of Siberian bloodsport, hockey's maybe the best place to see two pale honkies turn each other's faces into Pollock paintings.

    I have a feeling you didn't just shoot out of your chair, furiously fist-pump the sky, and scream "AWESOME!!!" Maybe it's a guy thing.

    Amy- Oh yeah, the old CF, a military term. I think it dates back to WWII, maybe even before. I'm going to base this on the loosely anecdotal fact that my grandfather (B-26, later C-130 pilot) used the term frequently when describing events from long ago and across the pond. JCAHO is pretty much your typical CF; a ton of people running around doing, well, not a whole lot of good.

    For those of you who find yourselves curious, yes, this post has been approved! It's so comforting, like a warm pile of linens fresh from the dryer. Or just a warm pile.

  48. Ruby, sorry to digress. And you're right, hockey leaves me...cold. We don't do hockey in California.

    Richter: Last thing. I can't sleep worrying about a teenage girl who is so angry, I have a foster son your age, and I'd be very concerned and sad if he had this much anger that he couldn't control. As a public school teacher and a Mom, I hope you'll go see your counselor (it's free!) I'm sorry for whatever has made you so angry: You don't want to stay this way, for your own sake. Life gets better after high school, you want to be able to enjoy it.
    Good luck, and yes, I know, I can go fuck myself. Take care.

  49. Devorrah,
    Anger is the natural state of teenagers of all species. The laid back friendly Tyranosaurus simply couldn't have enough kids to survive so eventually you end up with meanies. My own daughter makes those Columbine kids look like the Dali Llama, happily she takes out her aggressions on the softball diamond. I feel sorry for the instructor pilot who gives her a bad grade 5 years from now.

  50. Must be a girl thing--my boys are pretty tame in comparison! I'm glad I never had any girls. I was, of course, a horrible teenager myself.

  51. I'd like to go on record saying that it's much more fun when you guys dissect the JCAHO charlie foxtrot than watching the fairly thorough gangrape of whoever the fuck "richter" is. It's fun, he's annoying, and it feels good, I know, but JCAHO's a little more....uh......relevant.

    (Richter is amused. Richter is also trying to practise "safe commenting." Because, if Richter was banned, Richter would be bored, and Richter does not want to be bored.)

  52. Richter: Even my boys don't know what roflmao is. They knew the others. Help?

  53. Our hospital almost told JCAHO to shove it with the prospective medication review in the ER requirement business, but, oh, well, okay, I guess we'll make the staff wait 20 minutes for a pharmacist to approve an ibuprofen order from the triage nurse for a person who broke their hand and not tell JCAHO to shove it because JCAHO is God and doctors need help prescribing stuff.



  55. lol: laughing out loud
    roflol: rolling on floor laughing out loud
    roflmao: rolling on floor laughing my ass off

    Other acronyms as E.V.E.N.T.S. warrant.

  56. Hi Richter and Amy: OIC, and W/B. BTW, I'm glad Richter is NAD. Glad you decided to D/C the unsafe commenting, which was clearly AMA. Your comments are WNL. BTW, I'll BRB. We're off to the ED (really) because my son's been hiding an infected tattoo.

  57. Not to mention that you're more likely to get favorable patient satisfaction scores if you are a white male. The LOLs in NAD will take the time to write the hosptial how wonderful 'their sweet dear doctor' was when he looks like their grandson (or the grandson they WISHED they had).

    OTOH, the black and latino patients (if they can even write English) will likely NOT write anything, even if you were the bestest doctor ever.

    My point is, if you happen to be someone other than a white male, you're not as likely to impress the type of people who will likely take the time to write a positive review.

    I think that the PG scores are inherently racist, sexist, and biased!! Maybe I should do a study proving this to be true...and due away with all of the bullshit!!

  58. dear anon,
    you may have a point, but proving racism or bias is impossible unless you are psychic and i would argue against this plan and attack PG scores based on waste, fraud, and abuse. especially in the ER, let's rate physicians on patient outcomes and the like and stop there.

  59. Something more to ponder:

    TJC/JCAHO and CMS standards are becoming more and more similiar. Apparently there are several hospitals/facilities that are "subscribing" to the adherence of CMS standards/elements of performance in lieu of JCAHO/TJC-- which are, as a generality, more strict than JCAHO/TJC. Interesting.

    If you've ever read the specific JCAHO standards you'll also note compliance to meet the standards is relatively easy as a whole... facilities often seem to make the simple more difficult. ;)

    Lastly-- perhaps a better measure of "medical effectiveness" without measurement of "soft skills" (e.g., interpersonal skills-- which has been researched to demonstrate that it is a core component in clinincal competence) would be the IHI tools?

    PS: I do agree that Press-Ganey in the ER is simply and succinctly, retarded for the reasons someone has already stated. :)

  60. As a note, I work for Press Ganey. It is indeed the evil empire. I can tell you clearly that their focus is on money and not on improvement. This company works on a 40% gross margin on all products. The earned over $90 million last year alone on the mailing of surveys. It is hard for an ED to EVER get enough back to really be able to have valid and reliable data. National response rate averages for EDs is about 10%. Realistically, in most areas, it runs 6-8%. Most facilities simply cannot afford to get a valid sample.

    Something to keep in mind when looking at the data. Benchmarking is effective to see where you stand on the grading curve. On the other hand, it is something you cannot control. Your percentile ranking falls into the "area of concern". Your mean score falls into the "area of control". You can only work on your own facility, you cannot effect the outcomes of another. Administration needs to understand this basic fact and tie performance to that which can be controlled and effected. It is demoralizing to staff when they do not make their percentile rank goal. Take two facilities and say one has more buy in at the top and more resources to make things happen. Both have the save level of committed staff members. Logically, the greater resource facility will improve faster with all else remaining equal. Hence, the other facility see a lowered percentile ranking in comparison, even with the same amount of effort. Be aware of the benchmark, but focus on you!

    Let's be completely honest here, ALL survey companies fall into this boat. They have used statistical manipulation to pad their pockets and hold healthcare hostage. In the end, data is data. This is another commodity product. With Press Ganey you pay for a 23 year old college grad in South Bend that has little to no healthcare experience. What they provide cannot be justified at the price point you pay. For a hospital that has in excess of 100 beds the ED contract price is over $8000. Want to get the patient's comment? Add another $4100+ As far as mailing, to get the bare minimum for a report, add another $15-$18,000. Suppose you had 10 ED docs that you wanted breakout data. Hold onto your seats, but it would cost over $54,000 just for the mailed surveys! Over $66,000 a year just for data. Do yourself a favor, hire another nurse and find a cheaper provider.

    This company is changing by the day and its reputations is far from what it was. You can do better and you all deserve better!

  61. SPEAKING OF PROTECTION RACKETS! Yesterday every Press Ganey employee received a "Drive to 500" shirt. We are expected to grow this thing from $150MM a year to $500MM within 5 years! If you think you are paying a lot now for these surveys, think what this is going to do to your pricing on the next contract cycle! Can you say massive increase?

  62. Amen, brother/sister. I f-king hate how they hire extra housekeeping to polish the lobby before a surveyor comes, but let the needle boxes ( sharps) overflow the rest of the year, because there is only one housekeeper per two floors, and looking at them is like watching a drowning person.

    We now have posters up saying if "you are not ready to mark us as outstanding , please call 1 800 administrator so that we may improve our service" Service? I'm not giving you service, I taking care of you, whether you like it or not. If you didn't want an IV, why did you come to the ED? If you didn't want to be "bothered" every hour by your blood pressure cuff, then why are you in the ICU?

  63. Well, TJC is supposed to show up any day now, and we have all been basically informed that our jobs are on the line if we do not produce change in the satisfaction scores... Being a large suburuban teaching hospital that ranks at the top in quality, is just not good enough. If nurses don't push the dilaudid quickly enough, another poor score. If the fan control only goes to a 4, not a 5, another poor score. Think I am kidding here? Come on down and view the real world executives, if you think you can handle it.In the past, I never understood why people who were passionate about healthcare would just pick up and walk I know.