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Because I said so.

December 26, 2014

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.

Ah, but then comes 1965 and the passage of the Social Security Amendments.  There was a provision in this law that hospitals accredited by JCAH are “deemed” to be in compliance with most of the Medicare Conditions of Participation for Hospitals and,
thus, able to participate in the Medicare and Medicaid programs.  Bang!  All of a sudden the non-profit, independent, voluntary accreditation agency becomes a government contractor and money gets involved.  And that, friends, was the beginning of the apocalyptic power of the independent non-profit we now know as JCAHO.
Now, JCAHO is not a legislative body, not technically government, and thus isn’t subject to pesky rules about due process and open review periods for proposed regulations etc.  It can make whatever standards it wants.  Hospitals don’t have to follow the standards, but then they don’t get paid, so really, yes, they do have to.
So where do these standards come from?  Let’s take the case of medication management rules.  The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is a nonprofit organization devoted entirely to medication error prevention and safe medication use.  The president of IMSP previously served as Vice Chair of the Patient Safety Advisory Group for the Joint Commission (creates the National Patient Safety Goals) and currently serves as a consultant to FDA and a member of the Non-prescription Drug Advisory Committee (NDAC).   Oh.
OK, but JCAHO is nonprofit and not government-funded, so it can be non-partisan and impartial right?  JCAHO’s 2005 National Patient Safety Goals were approved at its July 2004 Board of Commissioners’ meeting. Tools and strategies for two safe practices, included among the JCAHO goals, were developed by the Massachusetts Coalition for the Prevention of Medical Errors with money from a grant.  The grand came from the Agency for Healthcare Research and Quality, a division of the US department of Health and Human Services.  Oh.
I can rebel silently by wearing my cloth hat under my hospital-regulation bouffant cap.  I could rebel openly by wearing my cloth hats only, risking the ire of the nursing management and probably getting in trouble with anesthesia administration, possibly losing my job.  If I don’t label my propofol, I risk my whole hospital losing accreditation and thus Medicare money and thus also losing my job, or at least most of the money that goes with it.  That is the power of arbitrary rules.




From → Healthcare

  1. Phillip Shaffer, MD permalink

    I am a radiologist who does a large number of breast biopsies using ultrasound or mammography. A few years ago, someone decided that we had to initial in ink the breast that we were going to biopsy. Totally nonsensical rule serving only to point out the ignorance of the rule makers. The rule apparently grew out of the OR rule that the surgeon initial the breast, or leg, that was going to be operated on. In that context it makes sense, since the arthropod can’t see the torn ACL. In our case, we are looking directly at the lesion we are to biopsy as we prepare to biopsy it. The analogy would be requiring a dermatologist to initial the side of the mole he was going to biopsy. So I simply refused to do it. This caused all sorts of angst amongst the staff. (As it turns out, I have always marked the breast with marks to help me orient the transducer and needle, but the marks aren’t my initials). I really was hoping I would get reported so that we could have a “discussion”. No such luck. Gradually, the enthusiasm for this waned. I suppose the rule is still there, it is simply properly ignored.
    The sad fact is that rules such as this are intended to impact the practice of medicine, and they are made by people who often have no idea what they are talking about. I have no respect for a system that produces such rules.

    • Thanks for reading! The problem with such rules is that their nonsensical nature and arbitrariness make the adherence to such rules either a sort of joke among staff or, worse, a mindless checking of boxes. Thus the systems problems such rules were supposed to solve are merely perpetuated.

  2. They’re just trying to use a nuclear missile to blow up a mosquito when they do this. Even among patients, JCAHO truly is a joke. Seriously.

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