JCAHO & Me

I will never understand the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). We recently had a unannounced visit from JCAHO, which is the hospital equivalent of a “surprise” root canal. On the one hand, I believe our section is well run and our activities are clearly transparent and well documented. On the other hand, no one enjoys repeated interrogation by different members of the JCAHO team. In our case, we had various people from JCAHO who marched into our section and proceeded to observe, comment, and quiz various staff on a large variety of topics. On successive days, we had different inspectors who often asked the same questions to the same people who were asked the day before. Patients were followed all around the hospital, and charts were inspected.

After several days, a preliminary group of “suggestions” was circulated. One criticism involved the administration of sedation in IR. In our hospital, any patient who receives any sedation above what is termed “minimal” requires a preprocedural history and physical (H&P). We do this for just about all our outpatient procedures with the exception of central venous catheters. I'm not aware of one single instance when this practice has proven beneficial to any patient, but I concede that it certainly doesn't impair our ability to deliver care either (unless you take into account the built-in delay of doing the H&P). If anything, I've always seen it as necessary overkill. The inspectors felt otherwise. One of the suggestions offered concerned our airway examination. The inspector wanted us to use the Mallampati scale. Had I heard of the scale? Yes. Did I know how to use it? No.

I had a discussion with one of our anesthesiologists regarding the utility of this scale:

Me: Dave, sorry to bother you, but JCAHO didn't like our preprocedural airway exam. Dave: What didn't they like? Me: They want us to use the Mallampati scale instead. What do you think about this? Dave: Well, we do use it before elective intubation, but the overall value and scoring system are debatable. Clearly, a Mallampati 1 airway is easier to intubate than a M4 airway. But is a M2 easier than a M3? And, one person's M1 is another person's M2. Me: Should we not sedate someone with a M4 airway? Dave: Well, you can probably still sedate, but do so with trepidation. Me: OK, great. But what is the significance? Clearly, we're not doing elective intubations in IR, and in the rare instances when intubation is required urgently during a code, I doubt you guys will be reading our preprocedural H&P. Dave: All true. I would place this in the category of not medically necessary but JCAHO required.

Another concern involved labeling of any and all containers on the IR back table. We have an unlabeled basin of sterile saline for most procedures. Because every tech, nurse, and physician in our section knows what belongs in the container (and it is never anything except sterile saline), no one ever thought to label it. I find this analogous to labeling a water fountain. But then again, you never know. Instead of water, I guess fire might come out of the spigot. But we do use labeled syringes for lidocaine, so I guess this isn't that unreasonable. I have and always will have concerns about liquids on the IR back table. For example, we never place chlorhexidine in cups because it could easily be confused with contrast. My “commonsense” strategy is to obviate risk completely when possible, not mitigate risk by labeling something that is not dangerous.

One of the inspectors noted that he couldn't read one physician's signature. I'd like to know how many of you out there have a legible signature. I'm not sure I've ever seen one. In any case, now we all sign our names and then print them out in block letters, like we did in kindergarten, right next to our signature. The other suggestion was to have a list of physicians' signatures posted on the wall so people could match the signatures with the physician. Now there's a good idea in the age of identity theft. We could include social security numbers and home addresses also, and might as well just leave a stack of signed blank checks there, too.

Ultimately, our section did quite well and did not receive any citations. The initial suggestions were not cited. Instead, I received the following e-mail:

The summation went well this morning. Many of the suggestions were not brought up as problems. [The lead inspector] said it's a good service and a great program. The only thing he mentioned specifically was a bathroom that staff are utilizing where the door opens inward and not outward.

I'll never understand JCAHO.