Because I said so.
Two articles in the October 2014 issue of Anesthesiology News caught my eye this week (I’m a little behind on my professional reading). Both talk about the arbitrary nature of rules.
In the first Dr. Robert Johnstone writes a hilarious rant on the randomness of the rules instituted by infection control wonks regarding OR attire. Some of my readers might be surprised to know that none of the things we wear in the OR are accompanied by any evidence that they prevent infection. Not even masks. I remember a few years ago there was an outbreak of some sort of infection in the neo-natal intensive care unit at my hospital. The NICU is on a separate floor and, in some cases, a different building from the operating rooms, and most OR staff never set foot in the place, nor do NICU folks frequent our operating rooms. Nevertheless, word came down from above that no one was allowed to wear cloth hats in the OR anymore. Huh?
The second article, in contrast to Dr. Johnstone’s, bows with respect, nay, subservience, to another set of rules. The Joint Commission’s Standards. The Joint Commission, or JCAHO, or “jayco”, is the much feared accreditation body for hospitals. Their inspections always result in a flurry of new rules that are enforced while the committee is in the building and are quickly forgotten after they leave. Halls full of equipment are suddenly cleared. Masks are donned and discarded every time we enter or leave an OR and are forbidden to be worn hanging down from your neck at any time. Long sleeves are banned. Propofol, a distinctive white substance with only one manufactured concentration, must suddenly be labeled with identity and concentration. Blue bell carts are suddenly locked. Someone comes up with the keys to the drawer under the anesthesia machine. Bathroom stalls have JCAHO talking points at toilet eye level.
Whence the power of this independent, nonprofit organization?
In 1910 a guy by the name of Ernest Codman, M.D., proposes the “end result system of hospital standardization.” The idea was a program that would track every patient admitted to a hospital to determine what treatment was used and whether it was effective. This sounds obvious to us, but remember that in 1910 most people with any kind of money wouldn’t dare enter the cesspools that were public hospitals.
Dr. Codman’s good friend and colleague, Dr. Franklin Martin, helped found the American College of Surgeons (ACS) and, of course, Dr. Codman’s idea became a stated objective of ACS. People liked the idea and within 40 years thousands of hospitals were inspected and approved by the ACS as having fulfilled standard of care practices. In fact, people liked the idea so much that The American College of Physicians (ACP), the American Hospital Association (AHA), the American Medical Association (AMA), and the Canadian Medical Association (CMA) join with the ACS to create the Joint Commission on Accreditation of Hospitals (JCAH). JCAH was a non-profit, independent organization who purpose was to provide voluntary accreditation of hospitals.
So far the JCAH was a bunch of doctors who got together, decided on some minimum standards for hospitals, and offered to evaluate any hospital that was interested to see if they met the standards. All very well, even laudable, and effective. Standards in hospitals rose considerably.