Reacting to an outpouring of criticism and valid complaints about the simplistic four hour pneumonia rule the Joint Commission ( aka JCAHO) emphatically demonstrated that they did not get the point and moved to correct the problem by increasing the time to six hours. They also amended the original rule by adding a diagnostic category called "diagnostic uncertainty", cases designated as such would not be included in the emergency department report card.
Predictably, some advocates of the rule complained that this category will set the stage for cheating.If the six hour clock has run out,those devious ER docs can place the case in that category.You just can't trust doctors, you have to watch them all the time.
Dr. Dale W. Bratzler,one of the creators of the pneumonia standards was paraphrased in the JAMA news report ( JAMA, April 25,2007-vol 297,no 16) as saying the JCAHO realizes that unintended consequences can emerge from instituting quality measures, but hospitals and ERs should not abandon attempts to improve care.That seems unlikely with the joint commission breathing down their necks.
When the planners are faced with a disconnect between their scheme and reality they amend the program but do not question their premises. Make the rules more complex, generate more stentorian admonishments, put new sheets on the Procrustean bed.
In his book "The Illusion of Technique" William Barrett said this:
"The absence of an intelligent idea in the grasp of a problem cannot be redeemed by the elaborateness of the machinery one subsequently employs"
3 comments:
There clearly are "unintended consequences" but were they not something that one could anticipate.The teach to test phenomenon in teaching is kin to the treat the chart phenomenon.If people will be penalized for an action one should not be surpirsed that they will take action to avoid the penalty even if lying and cheating are what it will take.
My understanding is that JCAHO/CMS have NOT done away with the 4 hour criteria. The JAMA article was somewhat misleading--the clock has NOT been reset to 6 hours. Rather, they have added in a data point to look at whether patients got antibiotics in 6 hours, in addition to their previous data points at 4 and 8 hours. The "benchmark" to which hospitals/EDs will be held is still 4 hours. Once data has been collected about the 6 hour time point, perhaps the benchmark will be shifted. I couldn't find information about this on their website, but that's what I gleaned from a phone call to 630-792-5085, the hotline for Core Measure Information.
Thanks to gregg for doing much better investigation on this issue that I did.
James Gaulte
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