J. Kent Garman

 

 

When most of us were in Middle School we began to understand that some of the rules Mom and Dad and the teachers set out for us seemed to be only for the benefit of the grownups, or in some cases, of no value to anyone. Somehow we learned to follow the rules if only to get to the next grade or to get a few dollars to go to the movies on Saturday. Other rules — like not running in front of railroad trains — we knew deep down were really a good idea, but we often tended to lump them into the resentment pile.

I wouldn’t want to tie life in Middle School directly to physician relationships with the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), but the parallels are instructive nonetheless.

JCAHO is certified (or “deemed”) by the U.S. government through the Centers for Medicare and Medicaid Services (CMS) to inspect and accredit hospitals and other healthcare organizations. Such accreditation is voluntary. However, CMS will not allow non-accredited organizations to bill Medicare. So connect the dots: we must be accredited or go out of business.

Most hospitals and physicians look on JCAHO as a necessary evil. It is not particularly “user-friendly” and since it accredits, its relationships with hospitals and providers are by definition adversarial — at least in the way its business plan is constructed.

Nevertheless, it is best to realize that as a whole, the accreditation process is generally productive and probably does improve patient safety. Results of accreditation surveys are becoming more public — JCAHO now publishes any hospital deviations of standards on public web sites. The public and legislators certainly are becoming even more insistent on oversight of hospitals and physicians and are not about to relax the process.

Here’s a recent JCAHO “good idea”: The joint commission wants hospitals and medical staffs to comply with new National Patient Safety Goals (NPSG). These are items that are developed by a new JCAHO committee, the Sentinel Event Advisory Group, that reviews recommendations for these goals.

A Sentinel Event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Loss of limb and function is included. Such events are called “sentinel” because they signal the need for immediate investigation and response.

The results are kept on JCAHO’s database anonymously and a new federal law allows the development of a national database on medical accidents and mistakes. (The information is masked to afford liability protection). This is similar to the aviation database that helps prevent aircraft accidents.

Naturally, all of this transparency provides rapid and direct accountability for Stanford Hospital and our Medical Staff. As physicians we have several key areas that we can address to make sure that SHC is not only fully up to speed with JCAHO standards, but more importantly, is a safe place to bring patients and practice medicine. To cite an analogy, airlines are required by the FAA to maintain their aircraft engines, but few of us who fly really think that’s the only reason they should do this.

There are several areas that JCAHO wants hospitals to pay attention to that physicians can directly impact. Each of the three are also “good ideas”:

1. Use of Unapproved abbreviations

It is true that all of us were trained in medical school to use certain abbreviations to write prescriptions. These abbreviations are ingrained into every physician’s brain and are very difficult to change. Are there real reasons to change? The JCAHO says the abbreviations — there are only six, amazingly — can lead to confusion and medical errors. The JCAHO also monitors their use. Connect the dots. The prohibited abbreviations can be downloaded or viewed by clicking [ Official "Do Not Use" List ].

Unfortunately, Medical Staff leaders have been asked by the Hospital to enforce non-use of these abbreviations. We have reluctantly agreed to do so. From now on, the total chart, including orders, written progress notes, and typed documents will be reviewed for unapproved abbreviations and violators will be required to complete an on-line course on the rules. Also, repeat violators may be subjected to further sanctions. I personally am not happy with a negative incentive for violators. I would much rather see positive incentives for those who comply.

2. Verbal Orders signed within 48 Hours

We all give verbal orders over the phone. Nurses take and act on these orders and enter them into the patient record. JCAHO and the State of California (Title 22), however, require that we then sign these already-completed orders within 48 hours. Many physicians look upon this requirement as intrusive and unnecessary, and it very well might be just that. Why should we have to sign, in person, an order that has already been completed? Nurses state that physicians, when asked to sign a day-old order, often deny having ever given the order.

All of these objections aside, this requirement is both state law and a rule of the JCAHO. If we are below a certain percentage of compliance, we will be cited as failing to meet this standard. As medical staff members, we need to help the hospital meet this standard.

3. Medication Reconciliation

Medication errors cause approximately 7,000 deaths annually in the U.S., according to the Institute of Medicine (2000). The JCAHO has published an NPSG requiring that patient medications be verified, clarified, and reconciled each time new orders are written for a patient. This includes admission, transfers, post-surgery, and discharge. Stanford implemented this standard in October 2005.

What are the medical staff and house staff expected to do to comply? It is actually rather simple. Nurses place a form on the patient chart listing dosage information and route of administration. The physician is then expected to review the list within 24 hours of admission, and at transfer, post-surgery, or discharge. After reviewing the list, the physician should check boxes that say “Continue” or “Stop”. After signing and dating, the physician’s obligation is finished.

Why would physicians be reluctant to do this? Reasons include time pressures and a feeling that this is just another form required by “bureaucrats”. Well, compliance with this form will actually save lives. But that being said, we must accept the fact that this form needs to be completed when requested by nurses. Thus far, we have not instituted sanctions for non-compliers, but I can see this coming if JCAHO records a poor physician compliance rate.

In summary, don’t use the prohibited abbreviations, do sign verbal orders willingly when asked, and do check the medication reconciliation form when asked. The hospital needs our help to meet these standards and your medical staff leadership really does not want to have to impose negative incentives to accomplish this. At the end of the day our patients need your help in completing these safety measures — whether the JCAHO is voluntary or not.

Thanks for your help. As always, please feel free to contact me and comment at kgarman@stanford.edu.