State of healthcare because of JCAHO

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militarymd

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So I'm call on a Saturday a couple of weeks ago on a Saturday. Did a bunch of cases in the morning and early afternoon....finish up and go home.

Then I get a page from the nursing supervisor...she tells me that our new vascular surgeon (just finished his fellowship at Mayo Clinic) wants to do a AAA in the vascular lab at 6 pm.

I ask for details, and what she told me is all that she knows. I'm annoyed, but I like the new guy, and I figure there must be some reason he wanted to do the case at 6 pm on a Saturday.....god knows what it could be, but I figure I would show up around 5 to set things up.

Well it turns out, that it was a contained ruptured AAA...hct 14%..creatinine 2+...and the vascular actually REALLY wants to go RIGHT now.

This is PP....There is NOTHING set up....no anesthesia machine in the vascular lab...no anesthesia tech...no CRNA....NOTHING.....

I told my friend to go ahead and get the patient ready and bring him down from the ICU while I get the lab ready to go from my standpoint.

I ask the OR circulator to get me ALL the blood that they had for the patient as I'm hooking up the machine...drawing up drugs......setting up IVs , warmers, and other stuff.

We do the case...and everything goes fine....EXCEPT I had to wait 50 minutes for blood!!!!

So life goes on....my next case is an Appy....we do that case...and in the middle of the case, the circulator realizes that we have no consent on the chart.

She was UNBELIEVEABLY distraught over the consent....nevermind, the patient walked to the OR for surgery.

She perservated over the consent for HOURS.....

So, here is the state of healthcare in modern day hospitals.....

No signed consent....BIG issues....nurses fret...incident reports get filled out....

Ruptured AAA patient with a hct of 14% has to wait 50 minutes for blood....no one bats an eye.
 
militarymd said:
So, here is the state of healthcare in modern day hospitals.....

No signed consent....BIG issues....nurses fret...incident reports get filled out....

Ruptured AAA patient with a hct of 14% has to wait 50 minutes for blood....no one bats an eye.
Click to expand...

Best quote I ever heard about JCAHO:

"JCAHO is a solution looking for a problem."

First thing we should do is get rid of this terrible organization that does nothing really to improve patient safety and everything to impede cost-effective and timely care. What is really suprising is the reaction of disbelief you see in people faces when you inform them that JCAHO is not a government institution and their "inspection" process is purely voluntary. Most people who work in the hospital do not know this and many, instead, believe that JCAHO is the Gospel as spoken by Jesus himself.

-copro
 
By what mechanism do you guys think the JOINT COMMISSION (caps to emphasize its all-importance) could possibly be dismantled?

I'd absolutely love to see it happen.

The JOINT COMMISSION is a goddamn cancer.
 
coprolalia said:
Best quote I ever heard about JCAHO:

"JCAHO is a solution looking for a problem."

First thing we should do is get rid of this terrible organization that does nothing really to improve patient safety and everything to impede cost-effective and timely care. What is really suprising is the reaction of disbelief you see in people faces when you inform them that JCAHO is not a government institution and their "inspection" process is purely voluntary. Most people who work in the hospital do not know this and many, instead, believe that JCAHO is the Gospel as spoken by Jesus himself.

-copro
Click to expand...

Awesome👍
 
JCAHO can only be dismantled by proving the interventions are not effective in keeping patients safe, or are not cost effective.
 
Last edited:
pain-ass-medal.jpg


in medicine for the year 2008
 
militarymd said:
So I'm call on a Saturday a couple of weeks ago on a Saturday. Did a bunch of cases in the morning and early afternoon....finish up and go home.

Then I get a page from the nursing supervisor...she tells me that our new vascular surgeon (just finished his fellowship at Mayo Clinic) wants to do a AAA in the vascular lab at 6 pm.

I ask for details, and what she told me is all that she knows. I'm annoyed, but I like the new guy, and I figure there must be some reason he wanted to do the case at 6 pm on a Saturday.....god knows what it could be, but I figure I would show up around 5 to set things up.

Well it turns out, that it was a contained ruptured AAA...hct 14%..creatinine 2+...and the vascular actually REALLY wants to go RIGHT now.

This is PP....There is NOTHING set up....no anesthesia machine in the vascular lab...no anesthesia tech...no CRNA....NOTHING.....

I told my friend to go ahead and get the patient ready and bring him down from the ICU while I get the lab ready to go from my standpoint.

I ask the OR circulator to get me ALL the blood that they had for the patient as I'm hooking up the machine...drawing up drugs......setting up IVs , warmers, and other stuff.

We do the case...and everything goes fine....EXCEPT I had to wait 50 minutes for blood!!!!

So life goes on....my next case is an Appy....we do that case...and in the middle of the case, the circulator realizes that we have no consent on the chart.

She was UNBELIEVEABLY distraught over the consent....nevermind, the patient walked to the OR for surgery.

She perservated over the consent for HOURS.....

So, here is the state of healthcare in modern day hospitals.....

No signed consent....BIG issues....nurses fret...incident reports get filled out....

Ruptured AAA patient with a hct of 14% has to wait 50 minutes for blood....no one bats an eye.
Click to expand...

you should send this people who actually make the rules on this. We are such a risk-averse, anti-litigious culture that it paralyzes our system. Our safeguards actually become hindrances and make it tougher for everyone to do their job.

I could give a thousand examples, but yours is pretty good.

When we got away from common sense principles is when life got less safe, more expensive, and more of a headache for everyone.
 
Another little Jackhole requirement is that all syringes are labeled with the drug, conc., date, and name of person drawing it up.


How many of you actually do this. Our pharmacy requested this of us recentoy and I said we will do it when they provide the labels premade for us with all req's on it.

They are working on it.:laugh:

BTW, Mil I don't respond to a nurse supervisor calling me about a case. I require the physician booking the case to call me. And this goes for all my partners. Why do you respond without the physician calling you? This is a weekend case. It must be emergent, right?

For instance, had an OB doc call the OR saying he is bringing a postpartum bleed to the OR. THe OR charge nurse calls me and I ask, "is she stable?" THe nurse obviously doesn't have a clue if she is or not. I run red lights to get there promptly. When I arrive the pt is totally stable and the OB is shooting the **** with her in the OR waiting for me. I put the pt to sleep and then I proceed to lay into the charge nurse and the OB doc. I read them the riot act and they apologize profusely. I tell the doc I will never respond to a nurse call again. We have a policy that after hours, the scheduling doc calls the anesthesiologist, period. I came in thinking he was too busy to call and in the process put others and myself at risk.
 
Noyac said:
Another little Jackhole requirement is that all syringes are labeled with the drug, conc., date, and name of person drawing it up.


How many of you actually do this. Our pharmacy requested this of us recentoy and I said we will do it when they provide the labels premade for us with all req's on it.

They are working on it.:laugh:

BTW, Mil I don't respond to a nurse supervisor calling me about a case. I require the physician booking the case to call me. And this goes for all my partners. Why do you respond without the physician calling you? This is a weekend case. It must be emergent, right?

For instance, had an OB doc call the OR saying he is bringing a postpartum bleed to the OR. THe OR charge nurse calls me and I ask, "is she stable?" THe nurse obviously doesn't have a clue if she is or not. I run red lights to get there promptly. When I arrive the pt is totally stable and the OB is shooting the **** with her in the OR waiting for me. I put the pt to sleep and then I proceed to lay into the charge nurse and the OB doc. I read them the riot act and they apologize profusely. I tell the doc I will never respond to a nurse call again. We have a policy that after hours, the scheduling doc calls the anesthesiologist, period. I came in thinking he was too busy to call and in the process put others and myself at risk.
Click to expand...


I'm glad you actually regulate what happens at your hospital.

I think in the situation that Mil describes, one of the biggest issues are nurese. We all know nurses are important. They serve a purpose. However, so much of their training is just protocol driven. For example, putting a Bair Hugger on for a 15 min case...ridiculous. Or wanting a Bair Hugger on when the temp of the pt is 37.0.

Again, I think it's just that unlike you Noy, most anesthesiologists dont stand up to the nursing hierachy. Most docs I know, unfortuantely try to cater to the nursing staff. i know there's politics involved and you have to be nice. But, again, physicians are giving up their power way to easily.
 
militarymd said:
...
No signed consent....BIG issues....nurses fret...incident reports get filled out....
...
Click to expand...

Reminds me of a case this week. County hospital + trauma services + motorcycles = B destroyed arms. The pre op nurse was throwing a fit because the Pt didn't sign the consent. It took slow and careful explanation on why the Pt couldn't actually SIGN the the consent.....
 
SleepIsGood said:
I'm glad you actually regulate what happens at your hospital.

I think in the situation that Mil describes, one of the biggest issues are nurese. We all know nurses are important. They serve a purpose. However, so much of their training is just protocol driven. For example, putting a Bair Hugger on for a 15 min case...ridiculous. Or wanting a Bair Hugger on when the temp of the pt is 37.0.

Again, I think it's just that unlike you Noy, most anesthesiologists dont stand up to the nursing hierachy. Most docs I know, unfortuantely try to cater to the nursing staff. i know there's politics involved and you have to be nice. But, again, physicians are giving up their power way to easily.
Click to expand...

I have seen the opposite. Docs are always telling the nurses to get a grasp of the situation at the facilities that I have work in. I can't think of one doc that catered to a single nurse unless he was involved with her. We have managed to make the nursing supervisors actually refuse to communicate b/w docs and it has worked quite well. The case I described was t the end of a slow day and teh nursing staff was still in the OR and still knew not to call me for the OB doc but thought that the case was a crashing pt. She now knows quite well why it i that we insist on being called by the physician.
 
Noyac said:
Another little Jackhole requirement is that all syringes are labeled with the drug, conc., date, and name of person drawing it up.


How many of you actually do this. Our pharmacy requested this of us recentoy and I said we will do it when they provide the labels premade for us with all req's on it.

They are working on it.:laugh:

BTW, Mil I don't respond to a nurse supervisor calling me about a case. I require the physician booking the case to call me. And this goes for all my partners. Why do you respond without the physician calling you? This is a weekend case. It must be emergent, right?

For instance, had an OB doc call the OR saying he is bringing a postpartum bleed to the OR. THe OR charge nurse calls me and I ask, "is she stable?" THe nurse obviously doesn't have a clue if she is or not. I run red lights to get there promptly. When I arrive the pt is totally stable and the OB is shooting the **** with her in the OR waiting for me. I put the pt to sleep and then I proceed to lay into the charge nurse and the OB doc. I read them the riot act and they apologize profusely. I tell the doc I will never respond to a nurse call again. We have a policy that after hours, the scheduling doc calls the anesthesiologist, period. I came in thinking he was too busy to call and in the process put others and myself at risk.
Click to expand...

not to be a douche here, but if you have to run red lights to get to a case, shouldnt they be paying someone to stay there?
 
SleepIsGood said:
I'm glad you actually regulate what happens at your hospital.

I think in the situation that Mil describes, one of the biggest issues are nurese. We all know nurses are important. They serve a purpose. However, so much of their training is just protocol driven. For example, putting a Bair Hugger on for a 15 min case...ridiculous. Or wanting a Bair Hugger on when the temp of the pt is 37.0.

Again, I think it's just that unlike you Noy, most anesthesiologists dont stand up to the nursing hierachy. Most docs I know, unfortuantely try to cater to the nursing staff. i know there's politics involved and you have to be nice. But, again, physicians are giving up their power way to easily.
Click to expand...

Sleepisgood, I hope you're kidding when you say that nurses want a bairhugger for a 15minute case. YOU decide what the patient gets. period.
 
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militarymd said:
So I'm call on a Saturday a couple of weeks ago on a Saturday. Did a bunch of cases in the morning and early afternoon....finish up and go home.

Then I get a page from the nursing supervisor...she tells me that our new vascular surgeon (just finished his fellowship at Mayo Clinic) wants to do a AAA in the vascular lab at 6 pm.

I ask for details, and what she told me is all that she knows. I'm annoyed, but I like the new guy, and I figure there must be some reason he wanted to do the case at 6 pm on a Saturday.....god knows what it could be, but I figure I would show up around 5 to set things up.

Well it turns out, that it was a contained ruptured AAA...hct 14%..creatinine 2+...and the vascular actually REALLY wants to go RIGHT now.

This is PP....There is NOTHING set up....no anesthesia machine in the vascular lab...no anesthesia tech...no CRNA....NOTHING.....

I told my friend to go ahead and get the patient ready and bring him down from the ICU while I get the lab ready to go from my standpoint.

I ask the OR circulator to get me ALL the blood that they had for the patient as I'm hooking up the machine...drawing up drugs......setting up IVs , warmers, and other stuff.

We do the case...and everything goes fine....EXCEPT I had to wait 50 minutes for blood!!!!

So life goes on....my next case is an Appy....we do that case...and in the middle of the case, the circulator realizes that we have no consent on the chart.

She was UNBELIEVEABLY distraught over the consent....nevermind, the patient walked to the OR for surgery.

She perservated over the consent for HOURS.....

So, here is the state of healthcare in modern day hospitals.....

No signed consent....BIG issues....nurses fret...incident reports get filled out....

Ruptured AAA patient with a hct of 14% has to wait 50 minutes for blood....no one bats an eye.
Click to expand...


Here's my song for JCAHO.

[youtube]http://www.youtube.com/watch?v=e0j0GCbMC7A[/youtube]
 
toughlife said:
Sleepisgood, I hope you're kidding when you say that nurses want a bairhugger for a 15minute case. YOU decide what the patient gets. period.
Click to expand...

Seconded. Hypothermia is an anesthesiologic problem.

If the pt's feeling are hurt, maybe the nurses can help with that. 😀
 
fakin' the funk said:
Seconded. Hypothermia is an anesthesiologic problem.

If the pt's feeling are hurt, maybe the nurses can help with that. 😀
Click to expand...

It 's only your problem after they are asleep....our circulators wrap them up like a burrito( so you can't put monitors on)....but then the SECOND the propofol goes in....the patients are lying there naked.
 
Noyac said:
Another little Jackhole requirement is that all syringes are labeled with the drug, conc., date, and name of person drawing it up.


How many of you actually do this. Our pharmacy requested this of us recentoy and I said we will do it when they provide the labels premade for us with all req's on it.

They are working on it.:laugh:

BTW, Mil I don't respond to a nurse supervisor calling me about a case. I require the physician booking the case to call me. And this goes for all my partners. Why do you respond without the physician calling you? This is a weekend case. It must be emergent, right?

For instance, had an OB doc call the OR saying he is bringing a postpartum bleed to the OR. THe OR charge nurse calls me and I ask, "is she stable?" THe nurse obviously doesn't have a clue if she is or not. I run red lights to get there promptly. When I arrive the pt is totally stable and the OB is shooting the **** with her in the OR waiting for me. I put the pt to sleep and then I proceed to lay into the charge nurse and the OB doc. I read them the riot act and they apologize profusely. I tell the doc I will never respond to a nurse call again. We have a policy that after hours, the scheduling doc calls the anesthesiologist, period. I came in thinking he was too busy to call and in the process put others and myself at risk.
Click to expand...

institutional culture....I got other things more important that I'm working on.
 
Noyac said:
Another little Jackhole requirement is that all syringes are labeled with the drug, conc., date, and name of person drawing it up.


How many of you actually do this. Our pharmacy requested this of us recentoy and I said we will do it when they provide the labels premade for us with all req's on it.

They are working on it.:laugh:.
Click to expand...

we pre-make "stat packs" for our OR's, to be stocked in pyxis with anesthesiologists' narcs. epi, atropine, succ, phenylephrine. it takes a few hours for us to make 20 syringes (enough for one days' worth of cases in our ORs)

we hate this, and imagine that the docs must, as well. my reasoning is that you are responsible for far more dangerous things than a stick of epi; why does everyone have to waste time on it?


hate JCAHO
 
coprolalia said:
Best quote I ever heard about JCAHO:

"JCAHO is a solution looking for a problem."

First thing we should do is get rid of this terrible organization that does nothing really to improve patient safety and everything to impede cost-effective and timely care. What is really suprising is the reaction of disbelief you see in people faces when you inform them that JCAHO is not a government institution and their "inspection" process is purely voluntary. Most people who work in the hospital do not know this and many, instead, believe that JCAHO is the Gospel as spoken by Jesus himself.

-copro
Click to expand...

Copro, I hate JCAHO as much as you do. We've been hearing for weeks now that they are in the area and may come at any time. All the nurses are in a heightened state of anxiety.

However, although the process is officially "voluntary" I thought access to Medicare funding was limited if you didn't get the JCAHO seal of approval. Doesn't seem so voluntary in reality to me if funding is at stake.

If I'm wrong, please feel free to correct me.
 
rsgillmd said:
Copro, I hate JCAHO as much as you do. We've been hearing for weeks now that they are in the area and may come at any time. All the nurses are in a heightened state of anxiety.

However, although the process is officially "voluntary" I thought access to Medicare funding was limited if you didn't get the JCAHO seal of approval. Doesn't seem so voluntary in reality to me if funding is at stake.

If I'm wrong, please feel free to correct me.
Click to expand...

You are right.
 
toughlife said:
Sleepisgood, I hope you're kidding when you say that nurses want a bairhugger for a 15minute case. YOU decide what the patient gets. period.

Give me 15 minutes with you in the OR to show you how you deal with that crap.
Click to expand...

Believe me it's outrageous. I'll tell them that it's unnecesary to put these things on and waste $$ for Bair Huggers. I'll tell them about Phase I, II, II heat redistribution. They dont get it.

If they want to put it on these things, they will for 15 min cases, I wont. Obviously, they have way too many things to do for the 15 min case, so it doesnt get done. Again, their minds are just 'protocol' driven. There's no science behind what they do.
 
coprolalia said:
Best quote I ever heard about JCAHO:

"JCAHO is a solution looking for a problem."

First thing we should do is get rid of this terrible organization that does nothing really to improve patient safety and everything to impede cost-effective and timely care. What is really suprising is the reaction of disbelief you see in people faces when you inform them that JCAHO is not a government institution and their "inspection" process is purely voluntary. Most people who work in the hospital do not know this and many, instead, believe that JCAHO is the Gospel as spoken by Jesus himself.

-copro
Click to expand...

Part of the problem is that the feds informed everyone that they would start regulating medicine more rigorously unless the hospitals could prove that they could competently self-regulate. Thus, JCAHO became much more active, changed their inspection policies (i.e. random times, inspecting clinical areas instead of just looking at binders in administrative offices), and generally creating solutions in search of problems.

You think the recent medicare rules change was annoying? (the 30day H+P, 7day H+P, signatures here, there, everywhere) Try the feds taking over all aspects of regulation and ENFORCEMENT.
 
SleepIsGood said:
Believe me it's outrageous. I'll tell them that it's unnecesary to put these things on and waste $$ for Bair Huggers. I'll tell them about Phase I, II, II heat redistribution. They dont get it.

If they want to put it on these things, they will for 15 min cases, I wont. Obviously, they have way too many things to do for the 15 min case, so it doesnt get done. Again, their minds are just 'protocol' driven. There's no science behind what they do.
Click to expand...



I am not sure how it is their call to put them on. If they put it on and YOU/STAFF feels it is unnecessary then take it off. Don't waste your time explaining science to them. They don't care if you paraphrase from miller.

On the few times they have put it on and I have felt it was not needed, I just turn off the bairhugger.
 
toughlife said:
I am not sure how it is their call to put them on. If they put it on and YOU/STAFF feels it is unnecessary then take it off. Don't waste your time explaining science to them. They don't care if you paraphrase from miller.

On the few times they have put it on and I have felt it was not needed, I just turn off the bairhugger.
Click to expand...

that's wht i usually end up doing..just not turning it on if they put it on.
 
rsgillmd said:
However, although the process is officially "voluntary" I thought access to Medicare funding was limited if you didn't get the JCAHO seal of approval. Doesn't seem so voluntary in reality to me if funding is at stake.
Click to expand...

No, you are correct. They have the ability to withold Medicare funding. This is the only thing that gives them power. And, they rely on the fact that most hospital administrators are so deathly afraid of getting put on Medicare suspension that they willingly kowtow to their often nonsensical and ridiculous demands.

What it would really take is administrators to stand up to and get behind the clinicians say, "Okay, you had your inspection. The suggestions you've made are ridiculous, time-consuming, cost-ineffective, and will do nothing to improve patient safety or timely deliverance of patient care. We are not going to implement them."

Then the ball is in JCAHO's court. Imagine the exposé on "Dateline NBC" on how JCAHO bullies hospitals and raises the cost to patients without really providing any safety net. They would be perceived as the bad guys, not the good they purport to be. Much of what they do goes unscrutinized because no one dares to challenge them.

This is a big problem with their review system; there is no "check and balance" to it. Hospitals and clinics just accept what they say because of fear of what might happen in accepting it.
What's worse is that JCAHO believes it has all the answers, and that answer lies in uniformity and protocols. This takes the responsibility away from the individual hospitals in developing new and creative ways to solve problems. And, some of JCAHO's solutions have no basis in delivery of more effective and safer care (such as limiting the amount of verbal-order "overrides" in medication delivery systems, requiring a pharmacist to review prescribed medications in the ED before given to a patient, etc.).


I'll give you an example... I had a patient I was transporting to the ICU who became nauseous on the way. As soon as I arrived in the unit, I said to the nurse, "Can you go grab some Zofran and give it to this guy before he pukes?"


Her answer was, "Nope. Can't do it. It's not on override. You have to place an electronic order. The pharmacist downstairs has to review it. Then, they have to release it in the Pyxis system. Then I can get it."


So, I had to leave the patient's bedside, find a computer, place the order, call the pharmacist downstairs and ask for them to "release" the medication, wait until it cleared our order-entry system, get the nurse also to leave the patients bedside, log into the Pyxis system, get the medication out, draw it up, and give it to the patient after he puked all over himself and the bed.


Now, tell me: How was the better, more-effective patient care?


JCAHO needs to evaporate. All they do is add cost and impede care. Let hospitals self-regulate. And, the kicker is that we already have the State DOH come and do regular visits. So, now we have two entities to answer to.


And people wonder why healthcare costs are skyrocketing and out of control... and I have to spend at least an extra hour (or two) everyday at the hospital filling out paperwork.


😡


-copro
 
rsgillmd said:
However, although the process is officially "voluntary" I thought access to Medicare funding was limited if you didn't get the JCAHO seal of approval. Doesn't seem so voluntary in reality to me if funding is at stake.
Click to expand...

No, you are correct. They have the ability to withold Medicare funding. This is the only thing that gives them power. And, they rely on the fact that most hospital administrators are so deathly afraid of getting put on Medicare suspension that they willingly kowtow to their often nonsensical and ridiculous demands.

What it would really take is administrators to stand up to and get behind the clinicians say, "Okay, you had your inspection. The suggestions you've made are ridiculous, time-consuming, cost-ineffective, and will do nothing to improve patient safety or timely deliverance of patient care. We are not going to implement them."

Then the ball is in JCAHO's court. Imagine the exposé on "Dateline NBC" on how JCAHO bullies hospitals and raises the cost to patients without really providing any safety net. They would be perceived as the bad guys, not the good they purport to be. Much of what they do goes unscrutinized because no one dares to challenge them.

This is a big problem with their review system; there is no "check and balance" to it. Hospitals and clinics just accept what they say because of fear of what might happen in accepting it.
What's worse is that JCAHO believes it has all the answers, and that answer lies in uniformity and protocols. This takes the responsibility away from the individual hospitals in developing new and creative ways to solve problems. And, some of JCAHO's solutions have no basis in delivery of more effective and safer care (such as limiting the amount of verbal-order "overrides" in medication delivery systems, requiring a pharmacist to review prescribed medications in the ED before given to a patient, etc.).


I'll give you an example... I had a patient I was transporting to the ICU who became nauseous on the way. As soon as I arrived in the unit, I said to the nurse, "Can you go grab some Zofran and give it to this guy before he pukes?"


Her answer was, "Nope. Can't do it. It's not on override. You have to place an electronic order. The pharmacist downstairs has to review it. Then, they have to release it in the Pyxis system. Then I can get it."


So, I had to leave the patient's bedside, find a computer, place the order, call the pharmacist downstairs and ask for them to "release" the medication, wait until it cleared our order-entry system, get the nurse also to leave the patients bedside, log into the Pyxis system, get the medication out, draw it up, and give it to the patient after he puked all over himself and the bed.


Now, tell me: How was the better, more-effective patient care?


JCAHO needs to evaporate. All they do is add cost and impede care. Let hospitals self-regulate. And, the kicker is that we already have the State DOH come and do regular visits. So, now we have two entities to answer to.


And people wonder why healthcare costs are skyrocketing and out of control... and I have to spend at least an extra hour (or two) everyday at the hospital filling out paperwork.


😡


-copro
 
IceDoc said:
Part of the problem is that the feds informed everyone that they would start regulating medicine more rigorously unless the hospitals could prove that they could competently self-regulate.
Click to expand...

I don't inherently have a problem with inspections. I think that there are some cheaters and cost-cutters out there who put the bottom-line above patient safety. I've seen it firsthand, actually. Just look at what happened in Las Vegas at that outpatient Endoscopy center.

Where I draw the line is finding the problem... then mandating a solution. It's one thing to point out deficiencies from good medical practice and standard of care. It is another thing to then say, "You have to do this."

What should happen instead is allow the hospital itself to fix the problem and come up with a solution. This allows de-centralization from the person finding the problem and mandating the solution. It further allows for ideas of better ways to fix things locally that work more efficiently for the individual healthcare system. What JCAHO attempts to do is make everyone implement the same solutions by requiring specific fixes to the problems they find.

That's the problem with JCAHO. They are both the policy maker and the enforcer. They need to separate those two things. Either that, or someone finally needs to have the balls to say that agree that there is a problem (or that the problem they found doesn't apply to them) and their solution doesn't make sense for their organization.

Imagine the political brouhaha that would happen if a hospital told granny that they couldn't treat her because some government-backed organization that has no day-to-day interaction with her said that they weren't complying with some ivory-tower mandate, or that they will have to charge her more and slow down the timeliness of her care to be in concert with some bureaucrats vision of patient safety?

JCAHO has to justify their own existence. That's why they keep coming up with more and more ridiculous mandates for hospitals to comply with. As soon as you are in full compliance with their current regulations, they have to dream up more stupid rules for you to adhere to or their won't be anymore justification for their existence.

Oh, and they're not done by a longshot...

-copro
 
Recently, one of the places I work in requires ted hose on all pts. undergoing surgeries lasting more than 45 minutes for DVT prophylaxis. A nurse was struggling to get them on a 75 year old obese female with thighs as large as my torso and smelled like she hadn't bathed in a week and asked for my assistance. In my best Southern twang, I said," Zip ain't gonna git all tangled up near 75 year old cootchie, Darling!" She rolled her eyes and presevered. Don't fight it, make light of it. Regards, ----Zip
 
coprolalia said:
I'll give you an example... I had a patient I was transporting to the ICU who became nauseous on the way. As soon as I arrived in the unit, I said to the nurse, "Can you go grab some Zofran and give it to this guy before he pukes?"

Her answer was, "Nope. Can't do it. It's not on override. You have to place an electronic order. The pharmacist downstairs has to review it. Then, they have to release it in the Pyxis system. Then I can get it."

So, I had to leave the patient's bedside, find a computer, place the order, call the pharmacist downstairs and ask for them to "release" the medication, wait until it cleared our order-entry system, get the nurse also to leave the patients bedside, log into the Pyxis system, get the medication out, draw it up, and give it to the patient after he puked all over himself and the bed.

Now, tell me: How was the better, more-effective patient care?
Click to expand...

Well, you've got to figure that the kind of nurse who believes in that system is probably also the kind of nurse who's liable to mess up and accidentally inject 2 cc of epinephrine instead of 2 cc of Zofran, if all the protocol hoops aren't jumped in the appropriate order. So maybe this IS better, more effective patient care than a nurse just grabbing a drug and giving it. 🙂

Those protocols are in place to protect patients from incompetent nurses. All the doublechecking, twin signatures on fluorescent orange stickers, drips etc made by pharmacists (doublechecked there too), tubed to the floor, picked up by nurse A and reviewed by nurse B before the 4 mg of Zofran can be given by "slow IV push" over 30 seconds (but only in NS or LR, not D5W 'cause the chart doesn't explicitly list Zofran as compatible with D5W) ...

Maybe the reason nurses love JHACO is because it protects their licenses from their own carelessness.

A few days ago while dropping off a patient I got in a fight with an ICU nurse because the red "high risk" medication sticker on the dobutamine bag didn't have my initials on it with a time and dose. The infusion wasn't running; in fact the bag was just hanging on the pole in case we needed it. She couldn't explain why I needed to sign off on a dose for a drug the patient wasn't getting, but by god the bag was there and it had a red sticker on it.
 
coprolalia said:
Her answer was, "Nope. Can't do it. It's not on override. You have to place an electronic order. The pharmacist downstairs has to review it. Then, they have to release it in the Pyxis system. Then I can get it."
Click to expand...

When I was an intern, one of my "jobs" in the unit was to stand there with the chart and painstakingly write out each order for "epinephrine 1 mg IV x1" while the patient was coding.

A similar issue happened with Levophed: I would tell the nurses, "Put him on Levophed!" then write an order for Levophed and fax the stupid order to the pharmacy so they would be able to get the Levophed.

Stupid $hit.
 
pgg said:
Well, you've got to figure that the kind of nurse who believes in that system is probably also the kind of nurse who's liable to mess up and accidentally inject 2 cc of epinephrine instead of 2 cc of Zofran, if all the protocol hoops aren't jumped in the appropriate order. So maybe this IS better, more effective patient care than a nurse just grabbing a drug and giving it.
Click to expand...
I agree essentially with what you are saying, pgg. But, this wasn't the exact problem here.The nurse simply could not get the drug out of the Pyxis until I put the order in. She wasn't asking me to do it to be in compliance. She physically could not get the medication. She still had to select the right medication, draw it up, and administer it as-per-usual nursing practice. The pharmacist had to do a cross-check for medication incompatibility (etc.).If I'd had the foresight to know this patient was going to get nauseous, I would've brought the medication up from the OR myself. But, needless to say, hindsight is 20-20.And, you raise a whole separate issue about individual accountability that I have frequently commented on in this forum. If you continue to make "protocols" and "diffuse responsibility" across multiple parties, then no one is really to blame when something goes wrong. It makes it harder to identify individuals who need remediation and more training... or to be in a different field altogether.What JCAHO is trying to do is take the individual completely out of the equation. This particular medication simply did not make the arbitrary "override" drug list (like other, potentially more dangerous, drugs such as epinephrine, morphine, dopamine... just to name a few). The set an artificial percentage of medications that can be on override, and if you have too many drugs on the list and it goes over that percentage, you have to re-adjust your list.The reason for this is completely beyond me. But, apparently, someone has determined that our system would be better if we have a pharmacist always check what a patient is given. This calls into to question the doctor's ability to make a sound medical decision. It calls into question the ability of the nurse to recognize a potentially dangerous interaction. And, most of all, it makes people lazier... and potentially more careless. They figure that they don't have to worry about whether or not there would be a problem with a med because someone else is going to check behind them.This is a HUGE problem, in my opinion, and removes the burden of good care (and learning) from the individual, slows down time to effective patient care, and puts more people on the hook for a bad clinical decision. And, what's worse, I really don't believe it makes the system inherently safer, because people stop thinking. All you've done is add more people to the mix where someone can potentially make a mistake.Instead of training individuals, we're creating systems. And, with those systems, mistakes are still bound to happen... a whole different kind of mistake. This reality is apparently completely missed on the JCAHO folks.-copro
 
coprolalia said:
Yeah, but if JCAHO has their way, you won't get away with such comments anymore...

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm

Sorry, Zip. The era of freely letting fly curt Lenny Brucisms is soon going to come to an abrupt end too... 1/1/09...

:laugh:

-copro
Click to expand...

"Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions."


if i can't be quietly uncooperative just shoot me now. just mind your voice intonation when you do...🙄
 
sevo85288 said:
Who regulates JACHO?
Click to expand...

No one. They are not a government agency. There is no real oversight. They are free to implement and continue their reign of terror as long as people continue to put up with it. The GAO is probably the only agency that can look into their dealings, but the GAO doesn't have any teeth.

This was interesting...
A Government Accountability Office (GAO) investigation requested by Stark, Grassley and Baucus and and completed in July 2004 found serious deficiencies in JCAHO's accreditation process. The GAO is in the process of conducting a second investigation relating to possible conflicts of interest and other concerns at JCAHO and its subsidiary. Today's letter calls into question JCAHO's ability to independently accredit hospitals while its consulting subsidiary, Joint Commission Resources (JCR), profits from the sale of products and services that aide hospitals in meeting accreditation standards.

Legislation sponsored in 2004 by Stark, Grassley and Baucus and (H.R. 4877, S. 2698) would have brought JCAHO's accreditation process under the authority of the Centers for Medicare and Medicaid Services in the same way that CMS oversees the accreditation of health care facilities other than hospitals. Congress did not act on their legislation. Stark, Grassley, and Baucus said today that they will introduce revised legislation based on a number of factors including any new findings of the GAO.
Click to expand...

http://www.house.gov/stark/news/109th/pressreleases/20060519_Hospitals.htm

Dare I call JCAHO "corrupt"? :meanie: While I'm glad that Congress didn't act on the legislation (unnecessary and more 'bloated' government), I'm surprised that there weren't heavier sanctions handed down.

This organization - and its terror tactics - needs to GO!

-copro
 
The hatred of JC is across the board. Even as a tech in the ER, I hated their damn inspections. It was the little sh** that distracted from the real problems: "Make sure the loaf of bread in the break room is not on the fridge, don't let the blankets hang over the edge of the shelf, if they ask you a question, respond with this scripted answer here in your badge holder.." Honestly? How many millions have we wasted because of them?
 
The only true victors concerning JCH from a physician standpoint are the physician owners of surgery centers and stand-alone specialty hospitals who are able to skirt JCH scrutiny, profit more because they also personally receive a facility fee in reimbursement.......oh......and along with that, patient satisfaction is higher since they are in and out CDAZY FAST since paperwork redundancy, question redundancy, and needless protocols/actions are nonexistent.

And they can fling their BIRDY FINGER at the JCH concept every day they show up at their facility, all the while offering a superior experience for the patient with the same quality of care at a JCH "inspected" hospital.
 
JCAHO's obnoxious rules and regulations take into account the least common denominator and apply it to all health care providers.
 
militarymd said:
Ruptured AAA patient with a hct of 14% has to wait 50 minutes for blood....no one bats an eye.
Click to expand...
I can tell you exactly why. Consent for surgery is now a "Red Rule"--something that can never be missed, ever. Failing to get a consent for surgery is now the equivalent of a sentinel event, as if someone was seriously injured or even killed.

JCAHO doesn't care about anything that matters.
 
coprolalia said:
I agree essentially with what you are saying, pgg. But, this wasn't the exact problem here.The nurse simply could not get the drug out of the Pyxis until I put the order in. She wasn't asking me to do it to be in compliance. She physically could not get the medication.
Click to expand...
Yep. Nurses hate JCAHO. It completely rules our practice, drives protocols, and affects our performance reviews. It's insane, and I don't know any nurse who likes it.

Examples:
I worked night shift at a hospital that did not have pharmacy in-house at night. Even so, if I called an MD and took an order, I had to fax the order to pharmacy before I could give the medication. Chart reviews were performed comparing the order time, fax time, administration time. But there was no one in the pharmacy.

Same hospital: TED hose required for every surgical patient. Emergency surgery? TEDs can't wait. Crash c-section? Same. If it wasn't documented that TED hose were put on before surgery, I got called on it. Insanity.
 
zofran is on the "override list" house wide in my hospital. and phenergan, too (replete with all the "new" administration warnings that go with it)

as system administrator, i decided that nurses should always be able to access anti-emetics, as:
1 - were i a patient, i wouldnt want to be waiting and nauseous
2 - honestly, how much pharmacist-review does a zofran order REALLY need?

the whole pyxis-profile/override JCAHO policies are absurd, and do nothing but cause headaches on the floor, cause headaches in the pharmacy (we are now very focused on getting orders processed very quickly, lest nurses be unable to access meds)

not safe or practical
 
tussionex said:
zofran is on the "override list" house wide in my hospital. and phenergan, too (replete with all the "new" administration warnings that go with it)
Click to expand...

The question is: What drugs did you have to "sacrifice" from the list to keep your override percentage within acceptable limits?

JCAHO. 🙄

-copro
 
JCHAO fun list

I can no longer ask my preop nurse to give the little munchkins some oral midazolam premed without going through the >30 minute pharmacy review process. Anxiety, unlike pain, is not considered an emergency. Thank goodness I rarely need to premed thanks to a creepy ability to woo most kids away from their parents.

In the procedure rooms, when I am doing the procedure, I can no longer give a verbal order for sedation. I have to stop what I am doing and write an order. Thankfully my sedation nurses see this for the BS that it is, but I am just waiting for the day that a new one shows up and decides to follow the letter of the law.

A JCAHO rep wanted to accuse one of my colleagues of having unlabeled syringes in his pocket. He had just drawn up a stick of propofol and had not labelled it yet when she walked into the room where he was setting up for a cardioversion. She grabbed the syringes out of his pocket. They were all labelled. I wish she would have tried to grab my syringes as I would have reported her for attempting to take controlled substances. Nobody touches my syringes without asking.

Nurses trying to put on bair huggers while I am trying to secure the airway. (If they try that s*** once I make a point of stopping everything until they are done. Then I pull the d*** bair hugger off and then I secure the airway)

I can hardly get through the door of the PACU without some nurse rushing at my patient with a thermometer to document whether they arrived in PACU "normothermic" I actually have to get them frankly febrile intraop to get the PACU thermometers to read normothermic, but I am judged by what the temp is on arrival in PACU. The older nurses are much better at realizing the true non-importance of this and can usually recognize when we need to get the important monitors on first. The younger ones meh.

When I emergently intubate someone on the floor, the ICU nurses have to wait for the sedation orders to be processed so they can start it up. Of course the medical and surgical ICU docs never think about sedation in the heat of the pre-intubation stress so the orders never get written until after I get the tube in. By the time the sedation orders are processed, the poor patient is waking up bucking and coughing. I have taken to carrying a 100cc bottle of propofol in my pocket when I am on call. After I drop the tube in, I reach into my pocket and hand it to the ICU nurse. My ICU nurses love me.

I could go on.

-pod
 
Last edited:
coprolalia said:
The question is: What drugs did you have to "sacrifice" from the list to keep your override percentage within acceptable limits?

JCAHO. 🙄

-copro
Click to expand...


nothing.
there are recommendations from Cardinal about Override Lists and "acceptable percentages" but nothing set in stone. We found clinical justifications for just about everything on our override lists.
we can audit overrides and see who's taking out what. it hasnt been much of an issue.

if you're too strict with overrides (or lack thereof) why even bother having the med on the floor?


JCAHO can go scratch.
 
jetproppilot said:
The only true victors concerning JCH from a physician standpoint are the physician owners of surgery centers and stand-alone specialty hospitals who are able to skirt JCH scrutiny, profit more because they also personally receive a facility fee in reimbursement.......oh......and along with that, patient satisfaction is higher since they are in and out CDAZY FAST since paperwork redundancy, question redundancy, and needless protocols/actions are nonexistent.

And they can fling their BIRDY FINGER at the JCH concept every day they show up at their facility, all the while offering a superior experience for the patient with the same quality of care at a JCH "inspected" hospital.
Click to expand...

i can't personally attest to the veracity of this statement, but it sure seems accurate and insightful. Thanks Jet.
 
First let me be clear that I am not an MD or med student. I have been an ICU/CCU nurse for 15 years and did a google search for "anti JCAHO" sites. I figured it was ok to post here. I agree with all the sentiments about JCAHO, and from a nurses perspective can testify that while they may have had a good purpose originally they now have become a self serving entity that used fear to perpetuate their existence.

The process of actually providing care for pts has bogged down in potocols and paper work. Almost anything needed to take care of a pt has to be behind locked doors, and documented endlessly. If a bag of NS is found on the counter without a nurse standing by it JCAHO will site you for leaving a potentially harmful "medicine" unattended. Magically, once you spike and start to infuse the NS it is no longer dangerous and can be left unattended in the pts room. Where they come uo with this stupid stuff is a mystery.

So how do we get rid of them. They hold hospitals hostage with the threat of losing Medicare reimbursments while at the same time increasing overhead because of all the paperwork they create. Most nurses and doctors I know would be happy to see JCAHO gone but are fearful of speaking out too publicly. Hospitals are not anxious to antagonize the people who hold thier fate in its hands.

I would be happy to join an organization dedicated to dismantling JCAHO, any suggestions?

Nukahiva
 
so how about it, Toughlife....

something for your plate?
 
militarymd said:
so how about it, Toughlife....

something for your plate?
Click to expand...

That sounds like a great idea. This is probably one area where the medical and nursing umbrella organizations could coalesce with the common goal of minimizing/eradicating JCAHO. I am surprised the AHA has validated JCAHO by acquiescing to their asinine requests in the name of patient safety. I guess they don't want to miss out on the paltry medicare reimbursements.

Nowadays, I can't even prelabel my syringes and leave them on my machine unless I will draw up my meds right away. Ridiculous.
 
Last edited:
Two words: Class-action lawsuit. (Okay, I guess that's technically three words.)

That's the only way you're going to chip into JCAHO. It's a private company, not a government entity. So, until you can get some lawyer (or law firm) to back us, we're going to keep kowtowing to this terrorist organization.

-copro
 
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