Today we learned about the Joint Commission, a hospital accreditation agency which exists to make life difficult for hospital executives and nurse managers. At least that’s that’s the impression I’ve got. It’s spending the week at our hospital.This morning we all arrived at rounds early, determined to get a good start with the senior attending, newly on duty. I had done an exemplary mental status exam on my two patients, and actually managed to write a note on both of them before rounds. Then, as we all sat down, one of the residents looked up and inquired about patient Luke. Whoops! That’s mine! I completely forgot about him, having picked up on call on Saturday, and having mostly blocked that day out of my memory. I dashed out, through two locked doors, grabbed his chart, came back through the two doors, and sat down. The resident then decided that she would just risk it, and take two minutes to go check on him, since she had forgotten him too.

No sooner has she left the room, than one of the interns observes that I’d better not have the chart in there, since the nurses will be upset if they miss it. Ok. My morning is already wrecked, I’m not going to argue. I run back through the two locked doors, return the chart to its rack. No sooner have I sat down, than the resident returns, having spent 1.5 minutes with the patient, and asks me for the chart. Yes. So she has to return through the two locked doors to retrieve the chart.

All this while, as we’re locking and unlocking our way out of the conference room, we’re all sitting in momentary expectation of the attending; everyone jumps to attention-in-a-sitting-position whenever the door is touched. And for 15 minutes me, and the resident, and a nurse, and a social worker, make our way in and out, to this silently clashing reception, before the doctor himself actually arrives. When he does get there, we’re all in place, me and the resident trying not to look like people who’ve forgotten one of their patients.

Well, this being the first day, he doesn’t eat anyone alive; he doesn’t even pimp anyone. He’s too busy getting acquainted with all the patients being handed off to him in mid-course. Halfway through, he announces inquisitively, “Luke?” The resident and I stare at each other across the room; the resident has not yet realized the depth of my delinquency, and imagines that I’m better prepared than she is. Finally, I blurt out, “Luke is a 40-yr-old man presenting with suicidal ideation for a month, probably due to drug abuse. He was, uh, feeling suicidal all weekend, and still feels that way today. We started him on Lexapro.” The attending turns to the resident. She says, “He was walking down the street with a rope, crying, and a girl stopped him. Actually he was feeling fine all weekend, and suddenly became suicidal this morning.” The attending says, “Ha; he wants to stay in the hospital. He has to leave tomorrow. Next patient.”

Whoo. The fact is, though, when I went to talk to him (thoroughly, because conscience-stricken) after rounds, he was feeling suicidal, and had been feeling suicidal all weekend. But he was looking forward to starting drug rehab, so I insinuated to him that if he wanted to get out to rehab, he had to stop acting suicidal.

At the end of the discussion, when we had all stood up to go walk around and talk to patients with the attending, he stopped suddenly and turned on our two guys. “I’ll start with you two,” he said. “What 15 procedures does this hospital have in place to ensure patient safety?”

The two of them just stared at him, and the two girls were equally shocked, sure that we were next in line. Pimping we were prepared for, but on a reasonable topic!

He repeated, “You: do you know the first six?” Blank stares, shaking heads. “All right then, get down to the library and look it up.” Further blank stares. “Ok; I’m making a point: you don’t know the answer, you need to stay out of the way because JCAHO is here all week. All of you. When you’re not absolutely working, go down to the library and keep out of the way.”

That’s our attending. That’s his idea of a joke. But we all got the point; in fact, the nurses all had the same idea, because by afternoon, the nurses’ station was almost depopulated, while the staff restrooms were chronically occupied. And the residents/med students’ room, a little square box, usually only used to stash purses in, suddenly filled up with four of us. We were informed in the afternoon that at another one of the psych wards across town, the JCAHO commissioners discovered some medical students while riding in an elevator, and asked them a question, and of course received gibberish in return, so that that facility got a very bad grade. Whereupon that facility now makes it an absolute rule that students and residents must leave the grounds entirely when JCAHO is around.

(In case you’re wondering what questions JCAHO asks, other than our attending’s example, I heard the nurse manager catechizing one of the nurses this morning right before the commissioners arrived: “In case of an emergency, how do you turn off the gas pipelines? And when can they be turned on again? And who is authorized to do so?” Which of course us “medical education” staff are never in one place long enough to learn. Besides asking questions like this, JCAHO pounces on charts, to discover if anyone has failed to sign every required line, or if anyone has used an outlawed abbreviation, or if any unfortunate resident has failed to turn in their dictation by the required time; and they search through patient rooms to see if suicide is truly impossible. And if the bathrooms are clean. And. . And. . . And. . . .)

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