Sunday, April 14, 2002

The Joint is Coming. The Joint is Coming.

Every three years or so most of our hospitals are visited by the Joint Commission on Accreditation of Healthcare Organizations. The mission of “The Joint” or “JCAHO” is “to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits nearly 18,000 health care organizations and programs in the United States. An independent, not-for-profit organization, JCAHO is the nation's predominant standards-setting and accrediting body in health care.”

For the emergency physician “Joint Commission year” at our hospitals includes reviewing the ED policies and procedures with our nursing colleagues and addressing issues in hospital-wide policies and procedures that include aspects relevant to the ED. We’re asked to review and update these so the policies and procedures reflect current reality. This is important work, but routine.

What’s not routine and critically important is reviewing any of the issues cited by the Joint Commission on their last review of your hospital and any new or revised standards with particular relevance to the ED. This year we are looking towards our Joint Commission survey in October or November and we’re particularly focused around the areas of moderate sedation (formerly “conscious sedation”), pain management and restraint management. Peer review is always an area for JCAHO scrutiny and recent standards updates are prescriptive in their requirements. We’ve substantially increased the detail in our peer-review policy and have been part of an effort that revamped peer-review across all departments and resulted in a new hospital medical staff peer review committee.

Moderate sedation in the ED is an increasingly common practice for the avoidance of pain associated with procedures ranging from fracture and dislocation reduction to incision and drainage of abscesses. As a colleague put it on the emed-l mailing list, “Expectations have changed. It isn't OK to use Brutane (2 nurses and an aide holding down a patient) for a painful procedure in this day and age.”

Credentialing for moderate sedation is a hospital medical staff function that is delegated to department chairpersons. A single hospital-wide standard is required, but that does not mean that the standard must be that of the Department of Anesthesia alone. In fact, once the Chairman of Anesthesia realizes how much moderate sedation is administered in your ED s/he will be delighted to support your credentialing process which should assure that emergency physicians are experienced with airway management (usually not an issue) and familiar with the pharmacology of sedating agents. The latter is usually tested with a single multiple-choice test used across the hospital for credentialing any physician who wishes to include moderate sedation as part of their practice. Working with the department of anesthesia to create the test will help win friends and influence people, especially as it will bring the clinicians’ perspective to an exercise that might otherwise be excessively focused on pharmacology. Your colleagues in gastroenterology, orthopedics and radiology will all thank you.

How might you address the pain management and restraint management standards? Your hospital and nursing staff have almost certainly already addressed this issue and created the policy and procedures necessary for implementing these standards. They’ve discussed what is expected from physicians as part of pain management and restraint management and have probably cajoled you to exhort your physician colleagues to do a better job in documenting pain evaluation and ordering restraints.

You and your colleagues can contribute effectively by working with your nursing staff through “open record audits.” Using the audit form your QA reviewers used on closed, completed records a staff emergency physician arriving 30 minutes early for a shift can review the records of several patients present in the ED at that time who have complained of pain or have been restrained. The engagement of the department’s own physician staff in the open record review helps convince nursing leadership and hospital administration of your interest and engagement.

The review with on-the-spot criticism from a physician colleague will speed learning and necessary behavior change so that the one-year of compliance necessary in advance of your JCAHO survey will be easier achieved. The effort of coming to work early for a few shifts each is not much, but will impress those with whom you work.

Peer-review is a specifically physician focused aspect of the JCAHO survey process. Standards promulgated more than 18 months ago now require a great deal of attention to and documentation of process that may have been handled less formally in previous years. Particularly with smaller, single hospital groups, the process now required including advance specification of who may participate in peer review, a process for gaining input from the physician whose care is under review and explicit criteria for seeking an external review must now all be incorporated into your departmental process. Consistent reporting of determinations so that data can be aggregated across departments and so that the medical staff can be assured that a sufficient number of cases are reviewed are all part of the new standard.

Getting started on JCAHO at least one year ahead of your anticipated survey will give you sufficient evidence of compliance with JCAHO standards, but living day-by-day in accordance with the standards while a worthy goal is a challenge made all the greater by the constant changes in standards. “Who moved my cheese?”

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