• Mitch Keamy Photo Mitch Keamy is an anesthesiologist in Las Vegas Nevada Andy Kofke Photo Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania Mike O'Connor Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago Rob Dean Photo Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.

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Since you are a questions person, here is one for you - how important do you find the litiginous atmosphere in the US as a contributor to this social engineering process and the thought process of the JCAHO?



So, let me answer for my buddy, Mike. Firstly, from a political perspective, (and I WAS a politician) doing something, even the wrong thing, gets more support than doing nothing. Rule #2 - when you're holding a hammer, everything looks like a nail. The Joint commission people aren't nefarious; they are just trying to make things better using the limited tools at their disposal; they have a big stick (medicare, medicaid and other reimbursements) but inadequate manpower to do real evaluations. And privately, they know it. Hence this superficial bean-counting (and I have shepherded my hospitals through six JCAHO surveys in jobs ranging from Chief of risk management to Chief of staff...)
To the extent that the core motivation of all these activities (litigation, accreditation) is to protect the vulnerable (patients) from the powerful (aggregated provider interests-"the machine"), they all derive from the same source. But of course, litigation is driven by individual consumer/attorney financial interests, and accreditation derives from societal/political motivations, and is potentially much more stifling in the long run. (at least I think so) Of course, our only recourse is self-regulation, which has never really worked in any industry either as an effective quality mechanism (read Arrowsmith or The Citadel) or as a political alternative. Thanks for visiting. We like your blog.

Mike O'Connor

First, I want to apologize for the delay in response.

As usual, Mitch is correct. That said, let me be clear: there are multiple forces pulling medicine in multiple different directions. They defy neat categorization into the usual classes of economics, regulation, and politics, because most of them necessarily span these boundaries.

An incomplete enumeration (and in no particular order) would include:

- 3rd party payors (e.g. United Health Care)


- State regulators (in Illinois, IDPH)

- Consortia (e.g. Leapfrog)

- Large provider networks (e.g. HCA)

- Vendors (pharmaceutical and equipment mfg)

- Litigation

Litigation and the threat of litigation vary in their influence on practice. Fear of litigation drives behaviors more in some settings than others, and perhaps more in some states than others. I'm not aware of any data (but there might be some) that suggests that care is less expensive in states that have tort reform - but my guess is that riskier services are more readily available in those states (e.g. high risk OB, neurosurgery).


Yes, but if JustComingAndHelpingOut ceases to exist, how will those people earn a living? When I label my propofol, which is a white liquid in a transparent syringe, because JCAHO tells the hospital to tell me to, so I won't confuse it with another white liquid in a syringe and inadvertantly inject the wrong drug, that is disingenuous BS. Of course, when they leave, it's back to business at usual with a wink and a nod, and the surprise visit and the 10000 dollar fine for me drinking coffee in the OR never seems to happen... etc etc. And my laptop comes back out, and I respond to this blog. JCAHO is OSHAs mutant spawn, grown from the early days of slaughterhouse health hazards, with metastasized tentacles into the modern day operating room. The resentment born of JCAHO leads to retaliatory disobedience, which negates any benefit of the unproven dictates anyhoo. Now, back to the hip.


Yes, litigation is driven by individual consumer/attorney financial interests, and accreditation derives from societal/political motivations, and is potentially much more stifling in the long run.

Sam Nisbett

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