Health Care Reform

Difficult days to be an inpatient: Joint Commission Day or July 1?

There was just something about the voice that peaked my interest. Normally, announcements in a hospital are muted, measured and perhaps even staid. But this one was not any of these.

The voice over the intercom robustly and frankly welcomed the staff of the Joint Commission.

Reflexively, I thought: “how nice of us to warmly welcome the inspectors.” But one breath later, I laughed out loud. Brilliant. Wrap the “they are here” message with a warm southern welcome. Huge Grin!

Now folks, you know that writing about the day that TJC visits your hospital would be akin to riding a narrow, treacherous, “high-consequence” single-track.

A mountain-biker faced with danger has two choices:

A.) Grab the gusto, focus the mind and let it rip. Commit.

B.) The more sensible–albeit blander–way of navigating such danger is to get off and walk. Live to fight another day.

So what’s a medical blogger to do when it’s time to recap the sensations of a TJC visit?  Ride the trail or get off and walk?


I would never write about how a normally calm, well-trained, well-meaning, all-human staff works less well when watched by people in suits. Serious people that hold the ability to–with a swath of a pen–assault something that caregivers hold precious: the self-esteem that comes from caring. Stop.

I won’t write about how it inflames my heart to see dedicated people get criticized by someone who has…Stopping here. Lots of Danger!

I would never say that a colleague described being fearful during a complicated procedure that was being observed by TJC. The worry was that the staff would do all the “right” things, but forget…Stopping again.

I would never even think that a nurse could not do two things simultaneously. Of course they can type in every box on five computer tabs AND tend to the patient. Hello. Everyone knows that we medical people can text click and care safely. And hospitals aren’t struggling, healthcare costs not skyrocketing because we have to hire one nurse to log computer notes while the other does nursing. That we have 5 people in the room for AF ablation in the US and two in Hamburg has nothing to do with why it costs 80,000$ here and 8000$ there.

And finally friends, you won’t ever see the essay–that I have written more than three times, but never published–on how the Joint Commission disallowed our ability to use the best sedative available. The fact that we had safely (zero breathing-related problems) used propofol for more than a decade and thousands of cases mattered not. Or that non-anesthesiologists now have two choices for sedating patients:

  • use anesthesia and dramatically increases the cost and limit access;
  • or sedate patients with far inferior drugs. Prolonged sedation after the procedure, nausea, retching and QT-prolonging anti-vomiting medicines are all on the come back in cardiac labs across the US–in the name of quality.

No way. The pursuit of quality dose not have unintended consequences.


Was there a third way to ride that trail?

Starting to go for it, but then seeing the danger; stopping short and dabbing. At least you tried.

5 replies on “Difficult days to be an inpatient: Joint Commission Day or July 1?”

I guess I am missing what you are saying about propofol? Is this some sort of fallout from the MJ case? Are you saying I would have to submit to a drug that was more dangerous or had more side effects? If so, what the hell is going on.
And yes, we are killing the system with inflated costs. My wife and I flew to Bangkok a few years ago for dental work. One tenth of the cost in the US and a wonderful vacation thrown in…

As for propofol, we, like many other labs in the US, had used propofol without an anesthesia doc. It’s how we trained. It’s how ablation is done in Europe now. We never had respiratory problems; patients loved it because they didn’t have nausea or retching afterwards. Not only that, but they were wide awake after the procedure. Propofol was amazing. True, you had to be careful, prepared and there was a learning curve.

The guideline-writers from Anesthesia deemed it not safe for “us” to use. To comply with these guidelines mandates hospitals had no choice. They could not consider the long-term safety records of the staff using propofol. They couldn’t write their own institutional rules. They just had to say no propofol without an anesthesiologist.For if they wrote their own protocol against the guidelines and just one patient had a problem…Well, you know what happens next.

So yes, US patients that require sedation–but without anesthesia–get lesser drugs. It’s a paradox: the safer drugs are less effective, longer acting, still capable of over-sedating and worse, they may make people retch.

Unintended consequences.

Thank you for this article. It’s an interesting read, although I feel I’m missing your point exactly. Are you saying that we shouldn’t have TJC-type inspections? There are definite unintended consequences, and the system is certainly not perfect — I work for the Canadian equivalent — but can you imagine working for a facility that was not accredited? Or more importantly, being a patient at one? My guess is that you wouldn’t do either; I wouldn’t. The “inspections” are like tests, and no one, from grade 1 upward, enjoys the test. But until a better approach is developed (and there have been systematic improvements in process over the past sixty years, both in the USA and in Canada), this is what we’ve got. If the testing makes people nervous and affects their performance on a small scale, the process will generally catch the systematic approach to care and to quality in an institution, and that’s a whole lot better than no standard or inspection overall, in my opinion. My guess is that you would agree with that.

Instead of propofol, why not just use Multaq? It has the same numbing and sedating qualities 🙂

So what will happen now? Will you use an anesthesiologist or worse drugs? I love the new short acting drugs, I no longer feel half dead for 3 days after an outpatient procedure.

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