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July 2002
Volume 66 |
Number 7
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ADMINISTRATIVE UPDATE
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| Accreditation
and Other Fantasies |
Thomas H. Cromwell, M.D., Secretary
Call it burdensome bureaucracy, bureaucracy run amuck or bureaucracy
justifying its own existence. I think you get the picture, but let
me clarify.
Case in Point:
A large hospital on the West Coast with 1,500 physicians on
the medical staff. The anesthesiology department consists of 50
anesthesiologists, most of whom trained at the University of California-San
Francisco; all are board-certified, many have subspecialty training
and six are now echocardiography-certified. The hospital has a
clinical load of 12,000 cases per year including cardiac and liver
transplantation. Bottom line: good department with excellent clinical
care. I can vouch for this as I had the opportunity to chair the
department for 17 years.
Over those years, I suffered through the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) reviews every
three years and was able to maintain a sense of perspective at
these intrusions by realizing that they were merely audits that
had little to do with true quality of care. Everyone concerned,
including the reviewers, seemed to realize that the entire process
was just another bureaucratic nuisance, the results of which could
be ignored until the next review three years later. At least these
intrusions did not interfere with patient care, so go ahead and
humor them, we told ourselves.
Then something changed!
We have now undergone three separate reviews within the past
six months with a fourth threatened "at a moment's notice."
What reviewers used to recognize as minor infractions in record
keeping that had little relevance to patient care have now been
escalated into major deficiencies that threaten an institution's
deemed status for Medicare's Conditions of Participation. In other
words, you are not capable of caring for Medicare patients. If
it was not so ludicrous, and given the level of reimbursement,
my response would be, "Throw me into the briar patch!"
Actual Scenario:
Survey #1 – 11/5/01. JCAHO/ California Department
of Health Services (DHS).
Results: No criticisms for department of anesthesiology.
Survey #2 – 1/8/02. "Validation survey"
by DHS, this time at the behest of the Centers for Medicare &
Medicaid Services (CMS) but conducted by essentially the same
individuals as the review two months previous, finds seven pages
of deficiencies that involve such things as failure to have postoperative
notes completed by the same anesthesiologist who delivered the
anesthetic and insufficient narcotic accountability according
to a plan acceptable to that particular reviewer. One interesting
criticism stated: "A review of one of 30 orders revealed
that an oxygen saturation reading was obtained on a hospice patient
without a physician's order." A heinous infraction to be
sure.
Survey #3 – 5/21/02. JCAHO follow-up survey. Formal
report pending.
Survey #4 – DHS, again at the behest of CMS. Threatened
"at any time."
Something is dreadfully wrong with the above-cited scenario!
We are caught between three warring bureaucracies (JCAHO, DHS
and CMS), each accusing the other of inadequate review. The process
that ostensibly accredits an institution to provide optimal patient
care is in reality little more than documentation of paper trails
by agencies of government that have no ability to assess true
quality of care and resort to mere audits of postoperative notes
and narcotic documentation. In my 25 years of experience with
JCAHO reviews, the reviewing team has never included an anesthesiologist,
they have never talked to an anesthesiologist about quality of
care nor have they ever actually come into an operating room to
directly observe anesthesia delivery. Yet they have the audacity
to declare the quality of care appropriate or otherwise!
Hospitals divert egregious amounts of staff time and money from
badly needed improvements to prepare for reviews, hire armies
of former nurses/administrators-turned-"consultants"
and perform endless mock surveys. Review teams are infested with
rogue reviewers who are free to interpret regulations as they
see fit, a task in which they are given significant latitude considering
Medicare regulations now comprise, believe it or not, 350,000
pages – four times larger than the Internal Revenue Service
code. Hospitals seek the latest buzzwords that seem to be in vogue
for reviewing teams, and hospital administrators, in their zeal
to placate reviewers, accept interpretations without challenge,
no matter how irrational or bizarre. Worst of all, the public
assumes that the seal of approval by the regulatory agency is
a guarantee of optimal medical care, but studies indicate there
is no relationship whatsoever. Despite extensive efforts by ASA,
a number of state components, the American Medical Association
and others to interject some rational thought into this process,
it is getting worse.
Having participated in various forms of peer review over the
years, I am an enthusiastic supporter, provided it is indeed peer
review. It must:
- Be conducted by clinicians familiar with standards of practice,
not self-proclaimed "experts" who are not anesthesiologists
and have no knowledge regarding the practice.
- Include extensive on-site discussion and observation of actual
practice, not a chart review for the presence of a postoperative
note.
- Be constructive with intent to improve clinical practice,
not be punitive, suspicious and destructive as is currently
the case.
- Follow established guidelines developed by professional societies.
In short, it should mimic the Anesthesia Consultation Program
of ASA!
Detractors (government) will scoff at the idea as self-serving
and expensive. It is my guess that it would be considerably less
expensive than the current government process, and the results
would be productive and mean something. The business of regulatory
review by government agencies has crossed the line from an intended
functional process to improve patient care to a hopelessly ineffective,
costly, appalling process that threatens, not improves, patient
care.
Enough is enough! We should stand up and be counted!
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