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    Two articles in the October 2014 issue of Anesthesiology News caught my eye this week (Iím a little behind on my professional reading). Both talk about the arbitrary nature of rules.


    In the first Dr. Robert Johnstone writes a hilarious rant on the randomness of the rules instituted by infection control wonks regarding OR attire. Some of my readers might be surprised to know that none of the things we wear in the OR are accompanied by any evidence that they prevent infection. Not even masks. I remember a few years ago there was an outbreak of some sort of infection in the neo-natal intensive care unit at my hospital. The NICU is on a separate floor and, in some cases, a different building from the operating rooms, and most OR staff never set foot in the place, nor do NICU folks frequent our operating rooms. Nevertheless, word came down from above that no one was allowed to wear cloth hats in the OR anymore. Huh?


    The second article, in contrast to Dr. Johnstoneís, bows with respect, nay, subservience, to another set of rules. The Joint Commissionís Standards. The Joint Commission, or JCAHO, or ďjaycoĒ, is the much feared accreditation body for hospitals. Their inspections always result in a flurry of new rules that are enforced while the committee is in the building and are quickly forgotten after they leave. Halls full of equipment are suddenly cleared. Masks are donned and discarded every time we enter or leave an OR and are forbidden to be worn hanging down from your neck at any time. Long sleeves are banned. Propofol, a distinctive white substance with only one manufactured concentration, must suddenly be labeled with identity and concentration. Blue bell carts are suddenly locked. Someone comes up with the keys to the drawer under the anesthesia machine. Bathroom stalls have JCAHO talking points at toilet eye level.


    Whence the power of this independent, nonprofit organization?


    In 1910 a guy by the name of Ernest Codman, M.D., proposes the ďend result system of hospital standardization.Ē The idea was a program that would track every patient admitted to a hospital to determine what treatment was used and whether it was effective. This sounds obvious to us, but remember that in 1910 most people with any kind of money wouldnít dare enter the cesspools that were public hospitals.


    Dr. Codmanís good friend and colleague, Dr. Franklin Martin, helped found the American College of Surgeons (ACS) and, of course, Dr. Codmanís idea became a stated objective of ACS. People liked the idea and within 40 years thousands of hospitals were inspected and approved by the ACS as having fulfilled standard of care practices. In fact, people liked the idea so much that The American College of Physicians (ACP), the American Hospital Association (AHA), the American Medical Association (AMA), and the Canadian Medical Association (CMA) join with the ACS to create the Joint Commission on Accreditation of Hospitals (JCAH). JCAH was a non-profit, independent organization who purpose was to provide voluntary accreditation of hospitals.


    So far the JCAH was a bunch of doctors who got together, decided on some minimum standards for hospitals, and offered to evaluate any hospital that was interested to see if they met the standards. All very well, even laudable, and effective. Standards in hospitals rose considerably.


    Ah, but then comes 1965 and the passage of the Social Security Amendments. There was a provision in this law that hospitals accredited by JCAH are ďdeemedĒ to be in compliance with most of the Medicare Conditions of Participation for Hospitals and,


    thus, able to participate in the Medicare and Medicaid programs. Bang! All of a sudden the non-profit, independent, voluntary accreditation agency becomes a government contractor and money gets involved. And that, friends, was the beginning of the apocalyptic power of the independent non-profit we now know as JCAHO.


    Now, JCAHO is not a legislative body, not technically government, and thus isnít subject to pesky rules about due process and open review periods for proposed regulations etc. It can make whatever standards it wants. Hospitals donít have to follow the standards, but then they donít get paid, so really, yes, they do have to.


    So where do these standards come from? Letís take the case of medication management rules. The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is a nonprofit organization devoted entirely to medication error prevention and safe medication use. The president of IMSP previously served as Vice Chair of the Patient Safety Advisory Group for the Joint Commission (creates the National Patient Safety Goals) and currently serves as a consultant to FDA and a member of the Non-prescription Drug Advisory Committee (NDAC). Oh.


    OK, but JCAHO is nonprofit and not government-funded, so it can be non-partisan and impartial right? JCAHOís 2005 National Patient Safety Goals were approved at its July 2004 Board of Commissionersí meeting. Tools and strategies for two safe practices, included among the JCAHO goals, were developed by the Massachusetts Coalition for the Prevention of Medical Errors with money from a grant. The grand came from the Agency for Healthcare Research and Quality, a division of the US department of Health and Human Services. Oh.


    I can rebel silently by wearing my cloth hat under my hospital-regulation bouffant cap. I could rebel openly by wearing my cloth hats only, risking the ire of the nursing management and probably getting in trouble with anesthesia administration, possibly losing my job. If I donít label my propofol, I risk my whole hospital losing accreditation and thus Medicare money and thus also losing my job, or at least most of the money that goes with it. That is the power of arbitrary rules.

    Found HERE
    Comments 2 Comments
    1. unconscious's Avatar
      unconscious -
      Silly attire is the smallest point of this piece which is really about "not for profits" creating regulatory capture of professionals...sound familiar?

      Jay
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by unconscious View Post
      Silly attire is the smallest point of this piece which is really about "not for profits" creating regulatory capture of professionals...sound familiar?

      Jay
      It wouldn't, perhaps, rhyme with NBCRNA, would it?
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