Machiavelli famously said to the prince: "It is better to be both loved and feared but if you can only be one, be feared". I've been wondering what Machiavelli would...
Anyone who has ever sat in a committee tasked with fixing a hospital quality issue knows that there are only three solutions that the committee can choose from. You can write a policy which will sit on a little known and even less used webpage on the hospital’s website. You can create a CBL, or Computer-Based Learning module, that are annual educational exercises for the hospital staff that are looked forward to with as much anticipation as a colonoscopy. Or, you can create a SmartPhrase to be used by the staff in electronic medical record progress notes that will never be used but will allow the committee to win the congratulations of the hospital administration who have no idea what a SmartPhrase is but it sounds really important.
Here is how it works. One of the hospitalists submits an incident report to the hospital’s anonymous quality reporting website because the coffee pot in the physician’s lounge was left on for 3 hours resulting in coffee that tasted like burnt pencil shavings. A member of the quality department pulls up Center for Disease Control’s website and notes that there has been a recent CDC advisory that there has been an epidemic of bad coffee in physician lounges in hospitals all throughout the country. As a result, surgeons and anesthesiologists nationwide have stopped drinking hospital coffee with the result of pandemic caffeine-deficiency headaches. Your quality staff then pull up The Joint Commission Standards and learn that according to standard 7.5.B19.#!&.4, coffee pots in physician lounges should be maintained in a temperature range of 91 – 96 degree Centigrade and coffee should always be disposed of within 84 minutes of being brewed. The hospital is in its window for its quadrennial unannounced site survey by The Joint Commission and the word on the street is that this year, the site surveyors are carrying thermometers to measure the temperature of coffee in physician lounges. Recently, a hospital in Cleveland lost its accreditation and was dropped from Medicare because a surveyor found 92 minute-old coffee in a nursing station breakroom.
The hospital’s legal staff determines that bad coffee qualifies as a sentinel event and assembles a multidisciplinary committee to provide a solution to the problem to the hospital administration within 14 business days. The committee meets 3 times and determines that the event is egregious enough that it warrants the highest response possible, the so-called triple response, consisting not only of a new policy, but also a CBL and a new SmartPhrase. The committee provides the following recommendation to the Medical Staff Administrative Committee:
- A new policy regarding the use of coffee machines in physician lounges. The policy dictates that only physicians credentialed in coffee making are permitted to operate the coffee maker. Physicians wanting to be credentialed must show that they have performed at least 20 proctored coffee procedures during residency or show evidence of attending an AMA-approved coffee making simulation course. Physicians must maintain logs to show that they have brewed at least 10 pots of coffee every 2 years in order to maintain hospital privileges. The policy also dictates that coffee pots must have both visual and auditory alarms when left on beyond 84 minutes and that the hospitals Engineering Services Department maintain logs documenting that the alarms are checked on a weekly basis. The new policy can be found on pages 42,789 – 42,796 of the hospital’s policy manual.
- A new CBL about coffee maker equipment. The committee recognized that not all physicians will be credentialed in coffee making and that many non-credentialed physicians will be drinking coffee in the physician’s lounge. Therefore, it was determined that all physicians must complete an annual CBL about safe coffee practices. There was concern expressed by some committee members that physicians who are tea-drinkers or who are Mormon should not have to take the new CBL but the committee ultimately decided that because it was theoretically possible that tea-drinkers could convert to coffee-drinkers and Mormons could convert to Catholicism, that all physicians should be required to take the CBL with no exceptions. After viewing the CBL, physicians would be required to pass a 20-question test on safe coffee procedures in order to maintain their medical staff admitting privileges. Included would be information about the correct use of FDA-approved calibrated measuring spoons for dry coffee grounds, disposal of used coffee grounds in biohazard receptacles, management of acute lactose-intolerance due to milk and cream, and safe storage of Styrofoam coffee cups. The new CBL turned out to be quite timely since a previous CBL on correct operation of the stethoscope was being retired that year, leaving only 499 required CBLs, and the new CBL would keep the total number of required CBLs over the hospital-mandated minimal of 500 per year that the physicians need to complete.
- A SmartPhrase to prompt correct documentation of coffee making procedures in case of audit by regulatory agencies. The committee members had observed that SmartPhrases are used to great effect in the electronic medical record to document in the physician’s progress notes their review of problem lists, review of medication lists, review of reviews of system, and listing of all hemoglobin measurements that the patient has ever had in their entire life. In fact, the committee noted that 95% of all of the progress notes was information imported into the progress notes using SmartPhrases that was not relevant to the actual care of the patient but was inserted into the progress notes in case the patient’s chart was ever reviewed by Medicare as part of a billing audit. Because documentation of coffee making has absolutely nothing to do with patient care and would only add unnecessary documentation to the progress notes, it was felt that this would therefore be perfect use of a SmartPhrase. One member of the committee raised the question of also creating SmartPhrases for the 10-day weather forecast, the 12-month list Dow-Jones Industrial averages, and the latest edition of the Dear Abby column as these could also add to irrelevant information in the progress notes but it was concluded that this was beyond the scope of the committee.
The hospital administration gleefully accepted the committee’s recommendation and thus another pressing quality issue was resolved.
The sad reality is that hospitals often use the convenience of a new policy, a CBL, or a SmartPhrase in order to “solve” a quality issue. What most quality issues really require is improved communication among staff and a change in the culture of the staff. But creating a policy, CBL, or SmartPhrase is simple and lends themselves to easy documentation and audit. Changing culture and communication is hard and difficult to quantifiably document or audit.
October 26, 2018