What JCAHO Knows

flying cadeuciiHere’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

American surgeons in 1918 started a system of reviewing hospitals because they were rightly concerned about serious differences in quality of hospital care and standards of practice. They wanted to evaluate hospitals objectively and motivate substandard ones to improve. In 1951, the American College of Surgeons joined forces with the American Medical Association, the American Hospital Association, and other corporate members to form the Joint Commission for Accreditation of Hospitals (JCAH).

As the organization’s scope of activities expanded, the name was changed in 1987 to the “Joint Commission for Accreditation of Healthcare Organizations” (JCAHO), commonly referred to as “Jay-co”, and then shortened to “The Joint Commission” in 2007.

The federal government didn’t pay much attention to healthcare quality until President Johnson signed the law creating Medicare and Medicaid services in 1965. Since the Joint Commission was already in the business of accrediting hospitals, the government decided to take advantage of the private sector’s expertise. Any hospital which passed Joint Commission review would be “deemed” worthy to take part in the Medicare and Medicaid programs.

Paying the Joint Commission to review their hospitals became much more attractive to hospital administrators once Medicare dollars were at stake, so more and more hospitals signed up. Today, the Joint Commission accredits and certifies more than 20,000 healthcare organizations and programs, encouraging them to feature its “Gold Seal” on their websites and advertisements.

A few competitors, such as the international firm DNV GL, have started to make inroads in the lucrative business of accrediting hospitals, but for the time being the Joint Commission holds a virtual monopoly in the U.S.

As recently as 20 years ago, a Joint Commission review was a benign experience for hospitals. The reviewers identified flaws or oversights that weren’t obvious, and made recommendations that actually improved processes of delivering care. Reviewers wouldn’t have dreamed of coming into the operating room during surgery.

As time passed, though, the low-hanging fruit was picked. Hospitals made major corrections, and national standards for many processes, such as sterilization of surgical instruments, were implemented. Hospitals across the country embraced the concept of continuous performance improvement.

Moving the targets

How could the Joint Commission stay in business? One answer is obvious: it can reinvent itself indefinitely by changing the rules and moving the targets.

Here’s a real-life example.

The Joint Commission decrees that syringes containing medications should be labeled with the name of the drug. No, that’s not good enough. All syringes should be labeled with the exact concentration in mg/cc as well as the name of the drug. That’s not good enough either. All syringes should be labeled with the drug name, the concentration of the drug, and the date and time they were drawn up. No, wait. They should be labeled also with the initials of the person who drew them up. And some medications should be labeled not with the time the drug was drawn up, but with the time it expires.

There is nothing to stop the Joint Commission from changing its rules ad infinitum,  guaranteeing reviewers jobs for life, and worsening the stress on hospital staff. While an external review could serve a useful function by sharing ideas and offering solutions, today it only scans for inconsequential details to cite as flaws.

Follow the recipe or treat the patient?

The Joint Commission benefits from the popularity of “evidence-based medicine” as a healthcare concept. Certainly it’s wise to use research evidence to guide healthcare decisions. But when the Joint Commission declares that evidence supports one treatment or medication as a standard of quality in healthcare, it forces clinicians to follow that recipe. If they don’t, the hospital will score poorly on its next review.

What if the quality of the evidence turns out to be poor?

Experienced physicians tend not to change their time-tested practices based on the latest study, as they’ve seen over and over that new data often fail to support an initial widely-publicized finding. They wait to see if the evidence can stand up to larger studies and closer scrutiny.

When you are a patient, you expect your physician to treat you as an individual. It makes sense to use research evidence as a guideline, not as a standard. For example, one Joint Commission standard of care is to give antibiotics for only 24 hours after surgery. This standard is tracked, and doctors are held accountable for meeting it.

But if you are a patient with diabetes or a poorly functioning immune system, you might be at higher risk for infection. You might prefer to trust your doctor’s judgment about how long you should be on antibiotics, without the specter of a Joint Commission review affecting the decision.

Physicians are pushing back against inflexible rules, realizing that they are management-driven, not patient-centered. Many patients have more than one medical problem. The application of a standardized protocol for one disease or condition may worsen another one. It takes physician judgment, and the knowledge of the patient as an individual, to make the best decision under the circumstances.

Meanwhile, at my hospital, the level of tension is rising as we anticipate Joint Commission review within the next few weeks. Experienced nurses are pulled away from patient care to make mock review rounds. Department chairs circulate memos about minute details that could trip us up. One chairman concluded succinctly, “These people are not your friends.”

As you think about the amount of the American GDP that is devoted to health care, remember that physicians and nurses would rather spend their time looking after patients than worrying about the next Joint Commission review.

And take my advice–stay out of the hospital if you possibly can when the Joint Commission’s reviewers ride into town.

Spread the love

17 replies »

  1. Read the following with horror:
    The Joint Commission benefits from the popularity of “evidence-based medicine” as a healthcare concept. Certainly it’s wise to use research evidence to guide healthcare decisions. But when the Joint Commission declares that evidence supports one treatment or medication as a standard of quality in healthcare, it forces clinicians to follow that recipe. If they don’t, the hospital will score poorly on its next review.
    The standard of “good” or “bad” medical care is decided by what the common wisdom of the monday-morning quarterbacks think. I’ve seen an argument here on the blogs whether gastroenterologists should, or should not, have anaesthesiologists present during conscious sedation for a colonoscopy.
    The concept of “When the gastroenterologist thinks it’s needed” was veritably laughed off the blog. Everyone knows they’re the LAST person you should trust – they’re only in it for the money!
    The coalition of the Blogwise agreed that it was indicated some times for most patients. During a JCAHO, the Papal Legation will look at such things, and note that they were done improperly – WHETHER OR NOT anaesthesia was used, it was the wrong decision.
    Queerly, the visitors do not “ding” hospitals much on an audit for avoidable deaths. So schedule your colonoscopy some other time than a Joint Committee audit. It will be done wrongly, say the mobile authorities.
    The last time I endured one of these, the pass rate, without restrictions, was 15% of all American hospitals. 85% were below standard. I’d heard that the outcry induced JCAHO to bump up the pass rate.
    As a physician, I was stopped by a JCAHO reviewer who asked me to, WITHOUT LOOKING AROUND, point to the nearest fire extinguisher. I could not; and they documented “fire extinguisher could not be located by staff.” They get paid to do such things. Your healthcare dollars pays for it, too.

    • PS: Sorry to be vague. I meant the object of the word “endured” to refer to a JCAHO audit, not a colonoscopy without anaesthesia. If I had a choice which one I would prefer to undergo, there’s no question. I’d unbuckle straightaway.

  2. In reply to Steve–your comment sadly is in line with our experience as well. On our last review, they wanted us to keep the anesthesia workroom locked, despite the fact that it is located in the central core of the locked OR suite which already requires ID badge entry. We protested, loudly, because this is where all the emergency airway equipment is located, and they backed off. However, it’s just another example of how the Joint Commission seems basically to wander around and make up rules. The amount of time devoted to dealing with it is unconscionable. See also: http://wp.me/p2bC3h-1r

  3. Reminds me when the young ‘uns wouldn’t sleep, I would threaten them with tall tales of Wee Willy Winkie.

    Watch out Jay Co is about!

    This completes the infantilization of medicine.

  4. My wife had some Inspectors visit her small outpatient imaging center last year. She had to tell them to shut up because they were gabbing and laughing in the hall outside her office while she was dictating. For some reason it took 5 of them to inspect an outpatient clinic.
    JCAHO= Jokesters Commisioned to Aggravate Healthcare Orgnizations.

  5. The commish was hijacked by the nursing advisory board a decade or two ago. Since then it has been a fearful group with limitless power mongering fear as a façade for excellence to mask their lack of real credibility.

    Nursing is burdened by a culture of fear. They make care dangerous by wrapping it in endless policies that no one can follow but by which all nursing care and individual nurses are judged. Doctors stepped aside and there you go.

    Today’s hospitals are run by nurses and other nonphysicians. They are not directly accountable. The docs have been neutered yet hold ceremonial positions of power. Medical staff structure with communication to the board has been subverted by the “task force” which reports to no board. The ACO is a nurse run enterprise based on government fantasy with the insurance industry as the puppeteer. The docs with the licenses are puppets for them.

    “Evidence based medicine” is a crock and a tantalizing phrase for regulators and uninformed patients. Research money flows there because it is the current fad.

    Organized crime should have it so easy. Maybe that is why they are opening nursing homes.

    All of healthcare should be handled like a hand grenade with no pin. Never take your eye off it. if you are near it.

  6. Well, interesting responses and pretty much in line with the critique I’m hearing. I wonder how much awareness there is of this on their part. At this point in the conversation it would be great to hear from someone at JCAHO or one of their inspectors – either on the record or off – to hear the other side of this …

  7. Now I have 2 times a year to tell my patients not to be in the hopital: July if the hospital has residents and during the JCAHO inspection. Its interesting that JCAHO has been inspecting hospitals for 60+ years and yet over 50,000+ souls are estimated to be lost every year to hospital-related deaths. If the FAA allowed the equivalent of over 300+ jetliners to crash every year, I am quite certain the FAA and the airline business would be changed.

    That has not happened in medicine. With the amount of money dependent on JCAHO and following their best practices, hospital administrators direct their efforts to follow instead of allowing innovation to thrive, thereby protecting their jobs, their certification, and their cash flow. With innovation stifled, the changes that the health system needs to develop affordable healthcare will not happen.

    As others have said, “Quis custodiet ipsos custodes?”

  8. Another sad point is that many of the reviewers are actually physicians and nurses themselves, and I’ve often heard it said that many of them are smart and well-intentioned people. It is a tremendous waste of their time and talents to put them on a trivia search. A recent review at a large New York hospital, for example, cited the hospital for putting a label that said “Water” on a sterile bowl on a surgical instrument table BEFORE the bowl was filled with water rather than after it was filled. Really? Is this the best that the Joint Commission can do to improve hospital safety?

    • Can beat that I think. They cited us for not having cleaning products in a locked cabinet. They were already in a locked room inside an OR that is also locked. Reason given? Someone could break into the locked room to get the cleaning products to use to harm patients.


  9. Inspectors are rarely popular. Although in this case at least some of the opprobrium appears to be richly deserved.

    Still, I wonder if this is as much a case of an organization evolving to reflect the marketplace as it is anything else. Look at another similarly maligned force in the hospital world: HealthGrades – a company that started out as a fairly harmless “good housekeeping” seal of approval – but has since mutated into a pay or play business model complete with a highly shaky statistical methodology (Al and Vik where is your health care by the numbers take down on this one,) . I seriously doubt their business would have evolved in the ways it has had it not be for the willing complicity of hospital marketing departments who knew a good thing when they saw it. Yet every hospital I’ve ever talked to hates them. This says something.

    An economist would – annoyingly, as usual – argue that this is simply a case of an institution evolving to reflect the businesses it serves.

    But the point about regulation is a good one. Who regulates these guys? Shouldn’t someone?

  10. Karen, kudos for having the guts to write this. Jcaho is absolutely a racket, as another commenter pointed out. What’s always amazing to me is how much running and hiding/enacting of stupid things (name badges anyone?) Goes on right before their visits. How is it that doctors are considered obstructionist to the great changes wrought by Obama, the EMR companies, and the insurers but organizations as fairly useless as JCAHO are exempt from all scrutiny?

  11. There certainly seems to have been a change in JCAHO requirements and rules over the last few years. For my first 35 years in medicine they had some good and bad requirements, but even the bad ones were not onerous. For the last 7 years they have been horrendous. I have ot think that they have no input from practicing physicians, just academics and retirees. Worst of all, there is absolutely no recourse or means to appeal their decisions. At this point, I absolutely hate the bastards. Note that i say this as one who has held administrative positions of some sort for nearly 20 years, in addition to working as a full time practitioner. I understand the need for rules. I think practice guidelines are mostly a good idea. However, JCAHO has become obsessed with minutia and surely must be part of the lawyer’s guild with the paperwork requirements they now push. They have become a negative force in health care.


Leave a Reply

Your email address will not be published. Required fields are marked *