Doctor’s advice: Beware of observers with clipboards

Here’s a doctor’s health tip for patients that I’ll bet you haven’t heard before.

If you’re a patient who walks into a hospital for an elective procedure of any kind–surgery, or a diagnostic test–and you find out that Joint Commission reviewers are on site, reschedule your procedure and leave. Come back another day, after the reviewers have left.

Why? Because every single person who works there will be paying a lot of attention to Joint Commission reviewers with their clipboards, and scant attention to you.

The Joint Commission has the power to decide whether the hospital deserves reaccreditation. Administrators, doctors, nurses, technicians, clerks, and janitors will be obsessed with the fear that the reviewers will see them doing something that the Joint Commission doesn’t consider a “best practice”, and that they’ll catch hell from their superiors.

For you as a patient, any idea that your clinical care and your medical records are private becomes a delusion when the Joint Commission is on site. Their reviewers are given complete access to all your medical records, and they may even come into the operating room while you’re having surgery without informing you ahead of time or asking your permission.

Perhaps physicians and nurses have an ethical duty to inform patients when the Joint Commission is on site conducting a review. Right now, that doesn’t happen. Does the patient have a right to know?

Unintended consequences

How did any private, nonprofit organization gain this kind of power? Why do American healthcare facilities pay the Joint Commission millions each year for the privilege of a voluntary accreditation review? It’s a classic tale of good intentions, designed to improve healthcare quality, that turned into a quagmire of unintended consequences and heavy-handed regulation.

American surgeons in 1918 started a system of reviewing hospitals because they were rightly concerned about serious differences in quality of hospital care and standards of practice. They wanted to evaluate hospitals objectively and motivate substandard ones to improve. In 1951, the American College of Surgeons joined forces with the American Medical Association, the American Hospital Association, and other corporate members to form the Joint Commission for Accreditation of Hospitals (JCAH).

As the organization’s scope of activities expanded, the name was changed in 1987 to the “Joint Commission for Accreditation of Healthcare Organizations” (JCAHO), commonly referred to as “Jay-co”, and then shortened to “The Joint Commission” in 2007.

The federal government didn’t pay much attention to healthcare quality until President Johnson signed the law creating Medicare and Medicaid services in 1965. Since the Joint Commission was already in the business of accrediting hospitals, the government decided to take advantage of the private sector’s expertise. Any hospital which passed Joint Commission review would be “deemed” worthy to take part in the Medicare and Medicaid programs.

Paying the Joint Commission to review their hospitals became much more attractive to hospital administrators once Medicare dollars were at stake, so more and more hospitals signed up. Today, the Joint Commission accredits and certifies more than 20,000 healthcare organizations and programs, encouraging them to feature its “Gold Seal” on their websites and advertisements.

A few competitors, such as the international firm DNV GL, have started to make inroads in the lucrative business of accrediting hospitals, but for the time being the Joint Commission holds a virtual monopoly in the U.S.

As recently as 20 years ago, a Joint Commission review was a benign experience for hospitals. The reviewers identified flaws or oversights that weren’t obvious, and made recommendations that actually improved processes of delivering care. Reviewers wouldn’t have dreamed of coming into the operating room during surgery.

As time passed, though, the low-hanging fruit was picked. Hospitals made major corrections, and national standards for many processes, such as sterilization of surgical instruments, were implemented. Hospitals across the country embraced the concept of continuous performance improvement.

Moving the targets

How could the Joint Commission stay in business? One answer is obvious: it can reinvent itself indefinitely by changing the rules and moving the targets.

Here’s a real-life example.

The Joint Commission decrees that syringes containing medications should be labeled with the name of the drug. No, that’s not good enough. All syringes should be labeled with the exact concentration in mg/cc as well as the name of the drug. That’s not good enough either. All syringes should be labeled with the drug name, the concentration of the drug, and the date and time they were drawn up. No, wait. They should be labeled also with the initials of the person who drew them up. And some medications should be labeled not with the time the drug was drawn up, but with the time it expires.

There is nothing to stop the Joint Commission from changing its rules ad infinitum,  guaranteeing reviewers jobs for life, and worsening the stress on hospital staff. While an external review could serve a useful function by sharing ideas and offering solutions, today it only scans for inconsequential details to cite as flaws.

Follow the recipe or treat the patient?

The Joint Commission benefits from the popularity of “evidence-based medicine” as a healthcare concept. Certainly it’s wise to use research evidence to guide healthcare decisions. But when the Joint Commission declares that evidence supports one treatment or medication as a standard of quality in healthcare, it forces clinicians to follow that recipe. If they don’t, the hospital will score poorly on its next review.

What if the quality of the evidence turns out to be poor?

Experienced physicians tend not to change their time-tested practices based on the latest study, as they’ve seen over and over that new data often fail to support an initial widely-publicized finding. They wait to see if the evidence can stand up to larger studies and closer scrutiny.

When you are a patient, you expect your physician to treat you as an individual. It makes sense to use research evidence as a guideline, not as a standard. For example, one Joint Commission standard of care is to give antibiotics for only 24 hours after surgery. This standard is tracked, and doctors are held accountable for meeting it.

But if you are a patient with diabetes or a poorly functioning immune system, you might be at higher risk for infection. You might prefer to trust your doctor’s judgment about how long you should be on antibiotics, without the specter of a Joint Commission review affecting the decision.

Physicians are pushing back against inflexible rules, realizing that they are management-driven, not patient-centered. Many patients have more than one medical problem. The application of a standardized protocol for one disease or condition may worsen another one. It takes physician judgment, and the knowledge of the patient as an individual, to make the best decision under the circumstances.

Meanwhile, at my hospital, the level of tension is rising as we anticipate Joint Commission review within the next few weeks. Experienced nurses are pulled away from patient care to make mock review rounds. Department chairs circulate memos about minute details that could trip us up. One chairman concluded succinctly, “These people are not your friends.”

As you think about the amount of the American GDP that is devoted to health care, remember that physicians and nurses would rather spend their time looking after patients than worrying about the next Joint Commission review.

And take my advice–stay out of the hospital if you possibly can when the Joint Commission’s reviewers ride into town.


Neal Koss

Good advice to patients about staying away from even the good hospitals (especially the good ones) during JCAHO review. My opinion is that the AHA and all the hospitals should just get up the courage to say, “Enough!” and just refuse. If nobody undergoes the review, then what is Medicare going to do about it?


Kelley Reep

Funny how doctor/nurse used to be the old adversarial relationship. We are all in it together vs. Big Regulators now. Beautiful article that sums up how every nurse I know of feels. The moving targets keep regulators employed, patients at risk, money wasted.


Even In Australia this is good advice when our hospital Accreditors are around. It’s sad that the responsibility and control over patient care/management has been increasingly taken over by bureaucrats and administrators – frequently based on little good and sometimes no good evidence.
However, in the ;long run we are the ones that have to answer for the care that we provide. It is long overdue for the professions (medicine & nursing) to take back control and say “no that’s not right”. If your JCAHC and our Accredictors want to dictate on patient care/management then it is up to us to say; “I don’t think that’s right but if you are insisting on this mode of management then you carry the legal responsibility for it’s outcome”. Have a pro forma letter ready to go to Administration and put the responsibility back in their laps – they’ll soon back off.


Kristina Port

Funny how the “house is clean when company comes (i.e., JCO), then sigh of relief, (when JCO leaves) and back to business as usual.


Bradley E Smith

Re Joint Commission: I wish I could write so well!
I acn remember when the inspections WERE friendly and constructive. Woe is me!


Morley Singer M.D.

Excellent article. Docs are known to change practices as ‘dress up’ for JCAH bureaucrats and then resume prior practices after JCAH leaves. Its valid to consider the current bureaucratic domination actually adversely affects quality of care.



Here in Singapore we are facing this similarly!The hospital that I am working at is going through its round of Joint Commission International reaccreditation round!The hospital administrators had began ‘preparations’for this week months ahead and I can’t help but agree with what you wrote!All these are causing all the healthcare workers added stress on top of the stress to provide good patient care on a ‘normal’ working day!




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