Joint Commission: Meaningful change?

June 2018 – Vol. 37, No. 5

James C. Denneny III, MD

The expanding list of rules governing how one practices medicine both in the hospital and outpatient setting has been recognized as one of the greatest threats to physician well-being in the medical community today. Whether it’s the EHR, documentation requirements irrelevant to best patient care, operating room attire, sterilization requirements, or “peel-packing” of outpatient office instruments, the frustration and anger is palpable. The cost of compliance in terms of financial resources in addition to physician and staff time is high and sometimes prohibitive at a time when both have exceeded rational limits. When you include the toll that these burdens take on physician resiliency and wellness, it is easy to understand the reaction we are seeing now.

As part of an updated strategy to present our concerns to the Joint Commission (JC), a survey was sent out this spring through ENTConnect and OTO News. We had a robust response of 158 members who contributed to the survey results. We asked six questions, including three that required a detailed response. All practice types were represented with 39.2 percent designated as private practice, 33.5 percent as academic, 18.4 percent as employed by hospital systems, and 8.9 percent representing military practices. When asked “What JC policies negatively affect your practice and wellness,” the respondents’ top answer was “Hospital/OR policies.” (See Table 1.)

In an esteemed and honorable profession, we physicians are charged with the responsibility to not only provide services that are in the best interest of our patients, but also to pursue policies that are good for our society. Accomplishing this lofty goal is neither an easy nor always an obvious pathway to chart. On this journey, we are tasked with assimilating our understanding of medical knowledge thus far accumulated and generalizing it to other similar healthcare scenarios. Sometimes this translates well; other times, such translation is imperfect.We also must realize that our actions do not occur in a vacuum, but exist in a complex interaction within a system and society. While we should pursue everything possible to secure the safety of the patients we take care of, it should be done so to maximize social good within the context of finite resources. What is an appropriate pursuit of a systematic intervention or policy for a given level of risk? When the evidence is shaky, it is too easy to fall back upon the “more is more” approach and apply the strictest guidance. Yet, while an ounce of prevention is worth a pound of cure, is a pound of prevention worth an ounce of cure?

As a body, the Academy is an advocate for both physicians and patients. If armed with reasoned dialogue and documented evidence, we can better partner with regulatory agencies and equipment manufacturers to advocate for responsible recommendations. Otherwise, if guided too much by emotion, our professional agenda may appear to be in conflict with our simultaneous role for patient advocacy.

— C.W. David Chang, MD
AAO-HNSF Co-Chair, PSQI Committee

The most common negative effect of JC policies was staff and physician frustration. (See Table 2.) When asked to list the most onerous policies as they affect the respondent’s practice, peel-packing office instruments was the Number One concern. (See Table 3.) It was difficult to accurately estimate monetary costs for the different practice settings, but the majority of respondents agreed it was over $10,000 per physician per year.

Some of the more notable quotations from respondents included:

  • “People wonder what happened to the ‘old time physicians’ … I think that a lot of empathy, generosity, and kindness has gotten beaten out of them … glad you asked.”
  • “The fact that I need to spend time on this survey is symbolic of how there are so many restrictions that serve no evidence-based positive patient care purpose, yet are inconvenient and wasteful of my time and money.”
  • “I could not begin to convince the JAHCO surveyor that this was a solution to a non-existent problem.”
  • “I cannot estimate the cost. One avoidable death is too many.”

There is a great need to pursue policy that is meaningful in terms of results through evidence-based data as well as that allows an efficient, cost-effective practice of medicine. We are working to establish foundations that allow both goals to be met.