Good intentions do not necessarily lead to good results. A case in point is the milestones initiative of the Accreditation Council of Graduate Medical Education and its various medical specialty boards, which are working together in an attempt to improve the quality of graduate medical education. In practice, however, the milestones are often not proving to be a valuable indicator of learner progress and are in fact acting like millstones around the necks of trainees and program directors.
The goals behind the milestones initiative are laudable. Introduced as part of the Next Accreditation System (NAS), they were intended to shift attention of learners and educators from processes to outcomes. They would foster self-directed learning and assessment and provide more helpful feedback. In theory, programs that were doing well would face less burdensome oversight and under-performing ones would receive more prompt and helpful guidance.
In practice, however, the milestones initiative has reminded many program directors and trainees of the onerous impact of maintenance of certification programs enacted by the American Board of Medical Specialties. Simply put, when the lofty rhetoric of initial assurances is set aside, the risks and costs of such initiatives appear to many to exceed the benefits by an unacceptably high margin. In many cases, this can be traced to a failure to assess outcomes before implementing system-wide change.
Here’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?
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).Continue reading…