Wednesday, December 23, 2009

Survey Scandals

Many people think that hospitals are large black boxes that function like The Great and Powerful Oz. Patients come in and patients go out, and nobody quite understands or oversees what goes on behind the pneumatic doors.

The fact is that hospitals are one of the most regulated types of institutions out there, and where mandated oversight is limited voluntary surveyors step in. One of the most well-known survey agencies is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now called simply the “Joint Commission.”) JCAHO accreditation of hospitals is a comprehensive process. Every three years, a hospital receives a team of surveyors who evaluate all aspects of hospital operations. The survey is “voluntary,” but in reality is mandatory because many third party-payers, Medicare included, will not reimburse a hospital for care if the facility is not JCAHO certified. The accreditation process by necessity focuses more on paperwork and less on patient care. This is simply a function of the fact that while patients are subjective and variable, paperwork is not. However, one can easily hold the impression that the Joint Commission process bears little relevance to clinical care.

For folks on the front lines, the Joint Commission visit is a necessary evil. Surveyors can ask anyone anything within reason, so we all learn where the policy books are located, the names of appropriate supervisors, and the answers to typical questions we might be asked according to a pre-set script. For example, we are all taught that in the event of a fire we would follow the mnemonic RACE (Rescue, Alarm, Confine, Evacuate/Extinguish) as opposed to our usual response, which is to sit and complain about the loudness of the fire alarm, ignore any possible signs of danger until the Styrofoam coffee cups melt, and then run screaming out the doors because we believe that heroes are people who by and large do stupid things and get away with it, and we are not heroes. We also have to memorize all our hospital alarm codes, which literally span the rainbow from Code Pink (Infant Abduction) to Code Brown (Weather Emergency…although that’s not what it means in the ED).

(If someone thinks I’m airing dirty laundry, please know that this is far and away not the case. Every hospital I’ve worked at does exactly the same thing. If this news to the JCAHO folks, they’ve not been paying attention.)

The biggest annoyance to us, though, is the restriction on foodstuffs in patient care areas. Accreditation criteria specify that no food and drink can be left open in patient care areas. (Patients can eat and drink in patient care areas, but nobody else can. Go figure.) This prohibition does make sense, as you probably don’t want a big dollop of sour cream from your chimichanga to accessorize your stethoscope, and Lord only knows what kinds of chimichanga germs (Staphlococcus tortillas) might get transmitted to a patient, especially if they were allergic to melted cheese. But in reality you can’t run an ED without having some kind of open container, whether it’s sodas for the nurses, sandwiches for the doctors (nurses get a set lunch time, while docs can leave the ED for lunch only if the patient load allows), cookies and pizza for staff, and coffee for everyone. To prohibit any kind of food or drink from being in the ED is deprive us of our greatest source of job satisfaction, namely sugar and caffeine.

(You REALLY thought I was going to say “patient care,” didn’t you? You haven’t been paying attention to this blog. Hahahahaha.)

Fortunately, our hospital understands this. That’s why when surveyors come around, they blast out over the PA system “WE WOULD LIKE TO WELCOME THE JOINT COMMISSION TO THE HOSPITAL AND HOPE THEY HAVE A GOOD DAY.” This greeting is, in reality, about 10% sucking up to the surveyors and 90% hospital code for “HIDE EVERYTHING.” Everything gets shoved into drawers, thrown into purses, stashed behind bottles of Gatorade in the patient food freezer, stuffed behind blankets in the linen cart (Tip: Drinks in cups and glasses taller than Coke cans will not reliably fit into the upper drawers of under-the-desk metal file cabinets.) We wait until we witness the passage of the suit-bearing Administrative Cluster (“They band together in small troops of five to ten,” says Marlin Perkins. “Now Jim will attempt to befriend a dominant male and separate him from the herd with a Golden Parachute.”) Once the “all clear” is sounded, feasting may again commence, with care to not pull things out of bags and drawers too fast or they spill.


Speaking of suits, one of our Case Managers brought a toy into the ED last week. Its little windup penguin that hops and waddles in a most amusing fashion. And every few seconds it ejects a small round chocolate pellet from its backside.

We instantly dubbed this toy the Administration Penguin, because as best as we can tell it’s sole purpose is to strut about importantly and drop…ahem, pellets…on the floor.


  1. I think you missed one wish....just can't remember which one it was. OH yeah, to have all your nurses wear string bathing suits under their scrubs in case your teeth need flossing.

  2. The best tip I ever received about how to deal with JCAHO questions was to answer in Spanish. Our hospital was in a heavily populated Latin area and we all were slightly fluent. It worked like a charm and at the time there was no rule that reponses had to be in English