21 March 2007

More JCAHO fun

All physicians hate JCAHO. Truly, it is an awful organization and they do awful things to the practice of medicine*. It seems like every year there is some new fad, some new measure that they are pushing down the throats of the people trying to practice medicine in a challenging environment.

I am sure there is some good that comes of JCAHO regulations. Their intentions may be good. But when you are the practicing doc (or nurse, God help them, the burden of the regs falls much harder on the nurses), trying to deal with a sick population, half of whom are uninsured, in an overcrowded ED with too few nurses and no inpatient beds and no specialists will to take call, the miniscule, petty, trivial, small-minded rules promulgated by this unelected bunch of bureaucrats can make you crazy.

For example, a couple of years ago, it was decreed that nothing could be stored under the sink in the ED. I have no idea why -- under the sink is a perfectly good storage place for non-medical supplies. They had to turn the ER upside down finding new legal storage places for the displaced stuff. And last year it was abbreviations. I agree that some abbreviations probably are confusing and should be clarified -- that's good common sense. But they came out with a list of dozens of abbreviations which are banned, many of which are perfectly clear (such as the use of L for Left and R for right). There is no appeal for their decisions, they are passed down from on high as infallible law, and woe betide the nursing manager if the department is singled out as deficient on a JCAHO survey.

The new rule, designed, it seems, to increase patient treatment times and decrease patient satisfaction and quality of care, is this:
All non-emergent medications must be reviewed by a pharmacist and mixed (if necessary) by a pharmacist.
Which sounds reasonable on the face of it until it collides with the hard reality:
We don't have a pharmacist in the ED. There aren't enough pharmacists to go around as it is, and now, instead of keeping the drugs in the ER and mixing them at the point of service (which isn't that hard), we need to send up to the inpatient pharmacy, wait for the PharmD to get around to it in their workflow, and send it back down. And we are not even talking about the dangerous stuff, but routine meds like certain antibiotics. Another interruption to our workflow, another delay in patient care, just one more in the death of a thousand cuts that is making health care that much more of an unpleasant profession.

And the scary thing is that this is an improvement from the original draft regulation, which said that all meds had to be reviewed in advance by a pharmacist.

Maybe that MBA might be a good idea after all...

* yes, this is hyperbole. get over it.


  1. All non-emergent medications must be reviewed by a pharmacist and mixed (if necessary) by a pharmacist.

    no fcuking way... tell me that's not true... perhaps we can get a PharmD on an ambulance to coax us along as well!

  2. as i call it, the JCAHO shuffle. got really pissed-off about them about a year ago when our institution really pushed the blood culture/antibiotic thing and spewed some of it onto my blog, but i have ceased to care.

    i don't want to start any rumors or anything but i hear that JCAHO routinely desecrats the Koran.

  3. JCHAHO is not a government agency is it? Is that why you do not have a due process to appeal their decisions?

    Nuclear power has INPO and NRC. INPO is an industry organization and if they make a finding or claim about your plant, T.S., but if you don't like what the NRC says, you have to be able to appeal it. Of course, there are way more hospitals than nuclear plants. INPO is pretty cozy with the industry, and I don't think they ever say bad things about plants.

  4. How about the required blood cultures for every patient admitted with pneumonia? How ridiculous is that!? If the patient is septic, yes, by all means blood cultures. But for many admitted patients with community acquired pneumonia, they aren't septic and are admitted because of hypoxia, co-mordibities (COPD, etc..) and age. Their blood cultures are always negative! Yet we must blindly follow JCAHO and waste $$$$ on blood cultures. A set of blood culture ain't cheap.

    I just attended a CMS meeting 2 days ago, wait until you hear some of the even more ridiculous "core measures" that they're gonna ram down our throat. It's coming very soon. And there ain't no way to stop this run away train.

  5. Geez---what a piss-poor rule.

    And I didn't know you couldn't write L for left or R for right. Is that just in orders? Or is it unacceptable in a note as well?


  6. Amen. If I ever found a magic genie lamp, and the genie granted me three wishes, first I'd wish for 10 million dollars, then I'd wish that I looked like a movie star, and THEN I'd wish that every JCAHO employee and Medicare big-wig be forced to work in an ER, a nursing home, and a home health agency for one year.

  7. No coffee or food in the nurses' station.

    We on the nightshift laugh at your silly rule, JCAHO idiots.

  8. Jim,

    JCAHO is an independent NGO which has no governmental authority that I am aware of. but CMS uses the JCAHO certifications to determine eligibility to participate in Medicare. So, like EMTALA, it's a non-binding binding regulation. We're free to ignore it, but not if we want to participate in the largest insurance program in the country.


    To my knowledge, the only prohibition on abbreviations is in orders (or at least that's the only place I have seen audited). Please don't give them ideas.


    Good one. I almost forgot that.

    CD and 911DOC,

    I think the blood cultures thing is pure CMS and not JCAHO. Not that it isn't asinine and hate-worthy.

  9. Every morning after work I pray to make JCAHO go away...then I wake up in a 4 hour presentation, on my day off at 9 in the morning telling me that in addition to everything else we have to do, JCAHO has added more core measures, and oh yeah, as nurses if we see things not being done (DVT prophylaxis) we should confront the MD about it. Yeah, right.
    I'm all for oversight, but it should come from people who are or have been in the trenches.

  10. We are now calling up to the pharmacy to get those ADDvantage vials of antibiotics tubed down, all antibiotics in fact, sent down instead of removing them from the Pyxis. This does nothing but delay patient flow. We know how to read allergies and read the name of the antibiotic on the vial. May as well just have ALL meds tubed down by the pharmacist if JCAHO is worried that nurses and docs can't do these two basic things.

  11. As difficult as JCAHO is, did you know that it has been really stepping up the regs for the administrators, too? The Leadership chapter is where all the good stuff is. They are SO on the hot seat now.(Patient flow is in that part, and if they don't have staff for boarding and holding patients, they are liable for it - kust thought you all might want to know where one of the skeletons is buried).
    Can't say I didn't get a little shiver when I saw that JCAHO had visited my blog, too! Eww!

  12. You always know when JCAHO time is coming in your hospital, because things get extra-stupid (ie, can't find item x b/c its logical storage place is verboten, etc). As a resident I had to resort to carrying guaiac card developer in my lab coat (shhh!) because suddenly all stool cards had to be sent to the lab to be read (it's blue/not blue, why is that so hard?).
    the best was when I was deployed to Iraq, and people starting referencing "JCAHO standard" when discussing issues in our COMBAT HOSPITAL. One of the only good parts of being deployed was freedom from some of the administrative crap. The admistration honestly seemed not to understand why mentioning JCAHO made the doctors want to set themselves on fire.

  13. As we say here at my hospital...Paperwork before patient care.


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