Just a visit from your friendly, neighborhood JCAHO inspector!
I came to work today only to find nurses and administrators in a state of subdued panic. I wondered why everyone looked like they had just seen werewolves; I was informed of the following: ‘Joint Commission is here!’ It was said in a whisper, with a glance over the shoulder. It was expressed with the same sort of emotion one might use when saying, ‘Comrade Stalin is stopping by today!’ Or maybe ‘The SS scheduled a visit!’
All afternoon, nurses and administrators have been running about, checking medical records, explaining inconsistencies, sweating blood over the mere threat of a sanction, a bad report, a raised eyebrow or a ‘tsk, tsk’ from the evaluators.
How has this happened? Wasn’t the whole idea of JCAHO to make hospitals better? Do we do that with fear? We’re told that torture does no good, but surely the anxiety caused by a joint commission comes close to the pain of an afternoon spent having your fingernails removed up to the elbow.
I think it’s tragic and comic. Here we are, nurses, physicians, administrators doing our best, day in and day out at hospitals with vastly different missions and capacities.
And yet, JCAHO descends like a pack of hyenas, dismembering order and good sense, and leaving all the staff scurring around in terror; and hiding their coffee cups, call schedules, food and anything else one might reasonably expect to see at any sane nursing station.
I wonder, what is the rate of medical error on days that JCAHO visits? There’s a study for you! Frankly, people could probably die for the nursing and medical staff gesticulating and genuflecting before the gods and goddess of the Olympian Joint Commission.
In the light of all this, explain to me one thing; why do we pay them to do this to us?
Edwin
Why, indeed!? I descended into the depths of hell last week rather than the well organized, pleasant ICU I have grown accustomed to working in over the last few months for what I thought would be an easy, 8 hour evening shift. Rather than finding my coworkers quietly charting over the dull dinging of redundant monitor alarms or gently fussing their ventilated patients into the very picture of cozy composure, I find my charge nurse sprinting from room to room with a light sheen of sweat on her brow as she checks the expiration dates on the bottoms of alcohol hand sanitizer found in each doorway. Her wild eyes fix on me with perhaps a smidge of relief as she practically yells over the cacophony of bells, whistles and beeps emanating from the central and bedside monitors for me to go smack our latest new grad out of her misty-eyed stupor in the corner. I wander towards said new grad while noting a general lack of nursing staff at the nurse’s station or bedside. What the heck is going on, I wonder? As I approach New Grad, she slowly raises her eyes to mine as would a beaten puppy and whispers in a tone one could only imagine hearing from a war veteran in a PTSD-induced panic attack, “I couldn’t tell them the difference between the FLACC, BOPS, and Wong-Baker pain scales”. Her voice escalates as she continues to whimper and I feel that she may indeed need a quick smack to bring her out of her reverie. Instead, I firmly grab her by her arms and demand she tells me what event has lead to this total and utter breakdown in our happy ICU environment. “JCAHO’s here”, she squeaks. Yikes, I think to myself with a wince, as this would also be my first unannounced JCAHO visit (somehow I have managed to dodge them since I started nursing three years ago). I usher poor New Grad back to her bedside where she goes through the motions of basic ICU nursing care like an automaton. On my way out her door, I stumble into Charge Nurse who gives me my patient assignment and asks would I please watch the two adjacent rooms as those patients’ nurse is currently getting the bare-feet-on-hot-coals treatment from a JCAHO surveyor in the medication room. I gather my charts and nurses notes and go to my bedsides to complete my shift assessments. I check on the other patients placed in my stead and return to the nurses’ station to chart. The smell of fear oozing from the nursing staff there was worse even than lactulose-induced diarrhea. The girls startle at my approach and turn around wide-eyed and then visibly relax again as they realize it is only me and not a staunch-faced, overdressed, demon-eyed JCAHO evaluator (no offense intended but they really are scary looking). “They have had her in there for over an hour”, one of my coworkers mumbles before she returns her pen to hover uselessly over her nurses notes. Another nurse, unable to stand the tension a minute more, gets up and goes to her bedside to re-bathe her patient in order to be “too busy” to stop for a survey. Why didn’t I think of that, I wonder as my nerves begin to grate along to the brisk beat of alarming coming from the central monitor. I resist the urge to go and silence them (or at least turn them down to a decibel safe for human ears) recalling the rule that monitor alarms must not only be on and audible but set within rigid and unrealistic parameters. I could use some coffee, I think next, and then quickly remember that I will not be allowed to sip from my hot, happy cup as I chart at the nurses’ station. I begin to scour my charts, searching for “mistakes”: unapproved abbreviations, unsigned orders, incomplete medication reconciliations and verify that my patients have completed fall checklists, so on and so forth. I surreptitiously get online (gasp!) and download the 30-PAGE MANUAL (seriously) of National Patient Safety Goals and distractedly thumb through them hoping I will magically absorb every goal and element of performance via osmosis. Suddenly, the door to the med room swings open and out drudges the nurse whose patients I have been watching. She who is usually perfectly coiffed and collected looks as though she had been molested in a dark alley. My feelings of distraction and dissonance swiftly escalate into hostility and resentment. What could possibly turn my clean and quiet unit full of gentle, caring souls whose daily tasks happily revolve around the security, comfort and health of our critically ill patients into this silently buzzing mayhem? What is this THING that has taken nurses from their bedsides to harangue them about hand washing and communication? With a huff, I push up from my desk with my heparin drip in my hand to join the others in hiding at my bedside. “Are you going to get that co-signed?” An acerbic voice says behind me. Like a prey animal catching the scent of a large predator, I freeze, knowing full well that it is too late to flee (run Bambi, run!) and then slowly turn to meet my demise. There she stands in all her self-imposed Glory wearing a ridiculous scarf and tall, pointy shoes with a dark waif at her side holding a clipboard and gnarled pencil, poised and ready to carve into stone my every indiscretion. A nervous, anonymous hospital administrator with sweaty hands hovers uselessly in the periphery. I hear scattered gasps among murmurs of sympathy as I paste on a sickly-sweet smile while starring daggers at Mrs. Glory and Waif. “Of course, I wouldn’t dream of hanging a concentrated anticoagulant without the prudence of another trusted nurse at my side”, I say, barely containing my sarcasm. She smiles hugely back, eyes wide and bright, as though she doesn’t catch the disdain in my words. Suddenly, I hear the soft tread of New Grad as she shuffles to my side without looking up towards Mrs. Glory. We make a big show of checking the bag against the order, verifying the dose, concentration and rate. I turn, heparin drip and New Grad in hand, and stalk off towards my bedside with Mrs. Glory and Waif in tow. We do another bedside verification and I begin to replace the almost empty bag of heparin for my new one. “Ahem, may I see”, says Mrs. Glory as she puts out her perfectly polished hand for my bag of heparin. I hold it out over my bed, making her step forward and bend closely over my rather odiferous trauma patient (the aroma I lovingly refer to a neuro-funk hanging in the still air). Her nose imperceptibly wrinkles as she catches the scent and she subconsciously arches herself over my comatose patient to avoid letting her scarf become contaminated by his bed sheets. Point for me. She checks the label and assures that it is a premixed bag from pharmacy containing the appropriate concentration of heparin. I program my pump for the appropriate dose and rate with New Grad diligently checking my math by hand as Mrs. Glory and Waif hold their careful vigil. Mrs. Glory nods with a faint frown seemingly disappointed that I did not error. Point two for me. After we finish, we return to the nurse’s station and both sign my MAR with a flourish. New Grad retreats and Mrs. Glory sits down in MY SEAT and runs her finger across the Heparin Protocol Order Sheet and then, not finding any errors, flips back to the lab section to ascertain that my coags are up to date. I look around the unit to verify that my other patient is still comfortable and safe during this twenty minute interlude (it should have taken two minutes at most) and observe that the color has returned to the once-pale cheeks of my coworker as she deftly re-collects herself after her inquisition. Charge nurse is on the phone, no doubt warning all the other units in the hospital or perhaps giving a pre-emptive verbal resignation to her supervisor. Family members are beginning to trickle in for visiting hours and I perceive that Mrs. Glory and Waif are suddenly interested in interviewing some of them. She closes my chart and grins up at me and offers a hearty “good job” as though I had just successfully resuscitated a level 1 trauma single-handedly rather than hanging a silly bag of Heparin. Where’s my cookie, I think to myself. I pick up my chart and turn to find another place to sit. Apparently unsatisfied, Mrs. Glory begins grilling me on Coumadin diets when my patient’s elderly wife approaches and taps me on the shoulder. “Good Lord, deary”, she huffs, “what is all the racket? I just know all that beepin’ and carryin’ on from these machines must be irritating my poor George.” I expertly explain about the monitor alarms while Mrs. Glory listens on and Waif records. “That’s just plain stupid”, says George’s wife before she turns to go to her beloved’s bedside. Mrs. Glory puckers and stiffly rises, flashing her eyes at me before turning to walk out of the unit. I return her glare and we all hold our breath as she sashays towards step-down with Waif trotting behind her. Those of us in her wake breath a physical and mental sigh of relief while watching perfect chaos ensue in front of her. Maybe now we can get back to actual patient care…the act of caring for another human being (we can chart it to death later).
Rochelle,
You are an artist and a voice of reason. A poet-patriot in the ongoing war against the madness of unstoppable, unaccountable regulation, whose soldiers are a vast army of consultants and other hangers-on, whose entire existence revolves around ensuring continued employment. They seem totally committed to instilling dread in men and women usefully engaged in helping others, as well as creating inefficiency in organizations that do just fine without them.
Write on! And please feel free to come back and comment at length any time!
Edwin
This happens every time in our hospital as well. Course, you didn’t mention that when you look for a nurse half of them are fighting the administrators for space in the bathroom because everybody has nervous diarrhea. My preferred strategy is to grab a mop from the housekeeper and mutter “no speak English…” And the inspectors–where do they find these people? Didn’t know there were that many rocks on the planet. And none of this, any of it, improves patient care. Not one iota. Mrs. George has it right: it is “just plain stupid.”
I freely admit to being one of the nurses that bathes perfectly fresh patients. They can’t follow me into the room because of patient privacy rights and I’m too busy with patient care for them to bother me. Perfect solution.
Of course, stretching out a tem minute bath into a three hour ordeal is difficult. But, by God, my patient is clean!
The only good thing about working in a Burn Unit was knowing those types wouldn’t dare come in a room where we were doing a complex burn dressing.
More evidence that RNs are indispensible. Great writing.
I also suffer from panic attacks and i can manage it by deep and slow breathing. i also practice meditation.. `