Is Joint Commission more hindrance than help?

[oldiebutgoodie]

I just thought I would throw this one out there:

Do you think that the activities that floor nurses must do to satisfy Joint Commission requirements are a help or a hindrance to patient care? It almost seems to me that we spend so much time documenting that a lot of patient care has gone out the window.

What do you think?

Oldiebutgoodie

[suanna]

Joint Commission is the oozing carbuncle on the back of health care and have been for years. If and candidate for the white house were to stand up an promise to abolish this useless organization they would win every nurses vote I know. I wonder what the cost of all the extra BS we do for Joint Commission? Get rid of them and the health care crisis is solved!!!

[NurseBean]

I think about rating pain and reassessment of pain. Correct me if I am wrong, but aren't these Joint Commission recommendations (dicatates)?

Where it sounds great in theory, it's a nightmare in practice. On a recent shift I worked, I had 5 patients (we have pretty good ratios, but most patients are train wrecks/in isolation/total care). 2 patients were chronic pain pts with Dilaudid ordered every 2 hours. Both were also clock watchers, and one actually would ring for his next dose 15 minutes after the last dose. Pain service was on board for both patients.

So, I had to document pain, document the Dilaudid, waste leftover Dilaudid, reassess pain, and document the reassessment every 2 hours for these 2 patients. I am sure this documentationa alone took 10% of my day (it seemed like more).

My fantasy is that all hospitals refuse to join the Joint commission, and we can get back to actually taking care of our patients.

Oldiebutgoodie

What's worse is when doc order pain meds every 30 min or every hr and the pt needs it that often... you have to assess (How would you rate/describe, etc your pain, grrrr) then reassess (with IV meds) in 5-15 mins!! And you are doing this every half hr to hour! how the heck are you supposed to do anything for your other patients!? But I doubt the docs have any clue about what out documentation reqs are so they don't get it. Otherwise if they were decent human beings they would just order a PCA!!

[CritterLover, BSN, RN]

i agree that much of the progress joint commission made in the begining was good. think about it: we had people dying from strangulation in their posey vests, sentinel events that were covered up, and the like.

many of the early changes that came about because of joint commission were positive, and in the patients' best interests.

however, they have outlived their welcome, by quite a bit.

i get very irritated by the notion that there has to be a better way of doing things, that the way we currently do things isn't good enough. progress is well and good, but sometimes we do things a certain way because it works.

this current safety kick that jc is on is about to push me over the edge. i'm all for keeping my patients safe, but some of the initiatives jc has come up with lately are putting patients at risk, all in the name of safety.

restraints is one instance. sometimes, it is in the patient's best interest to be restrained. i'm actually ok with some of the increased paperwork needed for restraining a patient -- makes it inconvenient for us to restrain someone. we don't want it to be easy, because we all know there are some out there who would over-use restraints if that were the case. however, it is becoming almost impossible to restrain patients in some facilities (even acute care facilities). that is putting patients at risk.

the pharmacy oversight on all medications is another problem. it makes it almost impossible to get a stat med stat. even if the med is in the pyxis, we can't access it until pharmacy links the med to the patient in the system. can't treat the elevated blood pressure, the low blood pressure, start those antibiotics, give that pain med......goes on and on.

there was a thread here not too long ago where the poster (a nurse) was talking about how long it took to get her pain meds post-op; she was in serious pain, and it took hours for her to get her meds. i see that kind of thing happen all the time now.

it used to be that we went and got the med out and gave a dose once we had the order. now we have to wait for the pharmacist to look at the order and approve it first, since it might conflict with something they are already on, or one of their allergies.... sounds good in theory, but in practice it is a nightmare. (not only that, but it causes conflicts with jcs other pet issue, pain management).

i suppose it wouldn't be too bad if there were enough pharmacists on staff, but they are short-staffed just like nursing is.

it reminds me a little bit of the federal mandate of background checks before people could buy handguns that started several years ago. i was living in arizona at the time, and there was a local sherrif that refused to do it. the way he put it was that congress might have made the mandate, but it did not give the local law enforcement the manpower needed to follow the mandate.

jc comes up with all of these rules/regulations, but doesn't give the hospitals any help to implement the standards. new oversigt positions get created (qi, pi, qa), and it ends up pulling nurses away from the bedside (either directly, through non-bedside nursing positions; or indirectly, through budgeting changes to fund non-nursing positions).

add that to the increased time that the remaining bedside nurses must spend on paperwork, rather than patient care, and jc has (in the name of patient safety) managed to compromise the number one factor that enhances patient safety: the attention of a nurse, monitoring the patient's status.

oversight is necessary, but jc is really out of control.

[oldiebutgoodie, RN]

Critterlover,

You make some great points, especially about obtaining drugs from the pharmacy. Another favorite of mine is when pharmacy calls to clarify an order--MD writes "Zofran 4 mg q 6 hours prn". The pharmacist (who really hates making this phone call) has to ask us to clarify the order-- PRN for WHAT condition? Well, gee, maybe Zofran for a broken arm? Of course it's for nausea, but according to the JC, none of us have any brains to make that connection.

Same for Dilaudid, etc. It's for PAIN, but of course I will have to rewrite the MD's order to clarify that it was for PAIN (I'm sure JC assumes I am calling the MD first to clarify the order).

I swear. It's enough to make ya crazy.

Oldiebutgoodie

[Katie82, RN]

Definitely a hinderance and mostly a waste of time and energy that could be put into patient care instead.

I agree that the biggest benefit of an inspection is that you have to clean out all the spaces that junk has accumulated since the last inspection. A Joint Commission inspection rates much more than direct patient care, which is what impacts us. I took a class at one Medical System I worked for, and we spent an entire day discussing Joint Commission. THey swoop in with a huge team. We only see the folks who come to the floor, but they are everywhere, from pharmacy to billing, to dietary, looking at everything. Six months later you get a list of "recommendations" - which you have a period of time to implement or lose accreditation. They are a huge pain, but consider the alternative. If a hospital were not regulated, what could they get away with???

[blueheaven]

A little of both, but I agree that it's gotten out of hand. If they come up with one more blasted form or paperwork for us to fill out I'll scream.

And how this paperwork affects pt. care?? Negatively as far as I'm concerned. You spend much of your time documenting in duplicate and triplicate for others convenience (the bean counters)

[dcarriv]

Is it possible that now it's just a matter of justifying their own existence?

even the doctors where I work say this

[CHATSDALE]

1] you [as an inspector] needd to maintain you job status..this is best accomplished by finding faults and mandating additional procedures and paperwork

2] paper work allows them to sit and peruse charts, which i am in favor of actually because i just hate for someone to go along on med runs

3] docs know that you can't write an order as PRN q 4-6 hours, this reg has been around for a long time

i believe that there are facilities who will try to get away with substandard care if not regulated but this does not mean that paperwork should multiply like rabbits

i have read of 'BLIND PATIENTS' i believe that is the term, in which a patient will be sent in for workup and they will report on care they received, how long they were kept waiting and how 'pleasant' you are when you are in their room i don't know if these are employees of the hospital or the joint commission

[Noryn]

Joint Commission is a joke. It has caused far more harm than any good it may have caused. They compound the workload for nursing by requiring useless documentation which results in less time for patient care. Patients do not get turned, cleansed, etc because of time constraints.

[FireStarterRN, BSN, RN]

I think about rating pain and reassessment of pain. Correct me if I am wrong, but aren't these Joint Commission recommendations (dicatates)?

Where it sounds great in theory, it's a nightmare in practice. On a recent shift I worked, I had 5 patients (we have pretty good ratios, but most patients are train wrecks/in isolation/total care). 2 patients were chronic pain pts with Dilaudid ordered every 2 hours. Both were also clock watchers, and one actually would ring for his next dose 15 minutes after the last dose. Pain service was on board for both patients.

So, I had to document pain, document the Dilaudid, waste leftover Dilaudid, reassess pain, and document the reassessment every 2 hours for these 2 patients. I am sure this documentationa alone took 10% of my day (it seemed like more).

My fantasy is that all hospitals refuse to join the Joint commission, and we can get back to actually taking care of our patients.

Oldiebutgoodie

I totally agree.

[hollyvk, BSN]

I was truly shocked a few years ago when I found out that they are not a government run group but a private company (in fairness I will add that they are non-profit) that has now progressed to holding health facilities hostage. I know for Medicare reimbursement one most be JACHO approved. I was also surprised that health facilities pay them for inspection/approval. How did a private company get so much power?[/quote']

I've worked in QA/QI and risk management, and here's what I know about JCAHO (now the "Joint Commission"--same initials as someone famous . . . ).

There is an alternative to JCAHO, it is a subentity of the American Osetopathic Assn. http://www.hfap.org/

The relationship between CMS (Centers for Medicare & Medicaid Services), JCAHO and acute care facilities accreditated by it is somewhat incestuous. CMS tells facilities they have to be accreditated to receive payment for caring for medicare and medicaid patients. Private insurance companies may also require facility accreditation as a condition for covering care.

So JCAHO saw a business opportunity and worked hard to fill it. I've been to JCAHO headquarters outside of Chicago (to check out job opportunities 15 yrs ago). It's a Taj Mahal of a building, fancier than most big banks headquartered in that area (can you say "fancy pink marble?"). Not only does JCAHO charge the facilities HUGE fees for the accreditation process, it also has a good income stream going with its business of selling accreditation reference materials (those wonderful JCAHO books). So JCAHO has managed to maneuver itself into being the "Good Housekeeping Seal of Approval" for healthcare facilities.

But does it really ensure good, safe patient care? Of course not. The old "wink and nod" system of letting facilities know when the accreditation team will arrive has finally been revised (now you get a window of time as to when they're coming), but it's not the "we could show up at anytime" scenario where a more typical picture of what's going on at the facility could be had. YOU and I are paying for this system indirectly as tax payers who fund CMS. CMS has been slow to require more from facilities via better accreditation processes.

So what has changed? Well, other financial players have started to assert themselves. Insurers don't want to pay for sloppy care that ends up costing them more money. And employers that are faced with the ever-increasing costs of health care plans for their employees have come to realize they can champion changes that might help hold down their costs. http://www.leapfrog.org

JCAHO is now scrambling to try and hold onto its preeminent acceditation position. So yes, you are probably going to continue to see "over kill" standards from them as they try to dance attention away from their real problems. And why won't JCAHO die? Because they're in bed with the facilities that know the true financial costs of the measures that would ensure better and safer patient care--better staffing ratios, a fully integrated physician order, test/procedure results and patient care documentation system, and more accountability from physicians.

Never a dull moment in healthcare . . . .

HollyVK RN, BSN, JD

[ebear, BSN, RN]

Thanks, hollyvk! So true. Politics at it's finest...