The Joint Commission on Accreditation of Hospitals and Healthcare Organizations (JCAHO) has recently named the hospital where I do much of my elective surgery a Top Performer. This means that it met ‘performance standards’ (JCAHO terminology) in key areas of patient care such as pneumonia, heart attacks, heart failure, and surgical care. It sounds great and is being publicized by the hospital marketing people.
Does this mean that the hospital actually delivers high quality care? Maybe. Certainly in some areas I am pleased with the care my patients get. But these performance measures correlate poorly with outcomes, as has been shown in several papers critical of the guidelines that make up the measures.
The guidelines are supposed to represent evidence-based best practice for specific conditions and to enhance patient safety. I can’t speak for the Internal Medicine based guidelines such as pneumonia care or heart failure, but at least in the surgical arena, the guidelines used by JCAHO have been demonstrated pretty conclusively to be at best clinically irrelevant. They have not shown any demonstrable improvement in surgical site infection or measurably enhanced surgical care. The few studies where enhanced safety or improved outcomes have been shown started with baselines that were below average relative to national standards. It isn’t hard to improve when you are already performing below the national average, and boosting your stats to average doesn’t prove that the guidelines will improve those centers that were already top performers.
“The emphasis is on compliance with the protocol, not on the critical assessment of what the patient actually needs.”
Meanwhile, thousands of person-hours are spent documenting compliance with these guidelines, and the criteria for compliance exceed the bounds of clinical common sense. For instance, if you are 1 minute early in giving your preop antibiotic (the standard is within 60 minutes of cut time), you have failed to meet the guideline. Give the drug exactly 60 minutes before incision and you are golden. Give it 61 minutes before incision and you are on the naughty list.
What the Top Performer designation really indicates is the zeal with which the organization enforces the guidelines and makes sure that all of the boxes are checked. Outcomes are not part of the measurement. Nurses and physicians are rated by how well they fill in the forms, not on how well their patients are doing. The emphasis is on compliance with the protocol, not on the critical assessment of what the patient actually needs.
The electronic medical record has only made this obsession with protocols worse. It’s too easy to add another check box or pop-up menu to the EMR in order to document your compliance with the rules. These check boxes now occupy the bulk of the nursing notes. A narrative nursing note of the events of the shift is a thing of the past. Dozens of pop-ups interrupt the order entry process with reminders to remove the urinary catheter and the need for a diet order and the possible interactions between medications the patient has been safely taking for years.
Discharging a patient now involves up to ten different forms that need to be filled out. The discharge instructions for all patients, even my 24-year-old cholecystectomy patient, include instructions about heart failure and chest pain regardless of what the admitting diagnosis was. The important instructions about wound care and follow up are buried at the bottom of the two-page discharge form.
My general assessment over the past 30 years of practice is that critical thinking has nearly vanished, nurses have become slaves to documentation rather than being allowed to actually get to know their patients, overall care has become standardized and impersonal, and the promised improvement in outcomes has not materialized.
So congratulations to my hospital on its Top Performer designation. Now how about taking care of the real issues in patient care.
Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.