Treatment Failure!!

or, When Good Regulation goes Bad

"Government regulation" is a troublesome subject. Quite often, from a consumer's point of view, I hear myself advocating for more regulation, as in medical providers and insurance companies should be required to make their billing practices understandable or banks shouldn't be allowed to charge all those fees. I'm sure I've said my share of things like that. And, as it's generally Republicans (i.e. the affluent and influential) who advocate for less government regulation, I'm reluctant to embrace the concept...we don't want things running absolutely amok, after all...we, at the lower end of the economic scale, know that if you give the rich and powerful an inch, they'll take a mile...and that mile tends to run right through the center of our houses...

Democrats and liberals (whatever that means) in general often make government regulation sound like its designed to help and protect little old me. And I think that is it's original intent.... most of the time, anyway. Like the regulation of hospitals, for example. I'm pretty sure that when JCHAO (probaby have that wrong..never was any good with those things) was established, government's intent was to protect the patients of hospitals from bad practice one way and another. Of course, JCHAO, isn't, itself, a government agency...it's a private business, as I understand it, contracted by the hospitals themselves to provide "certification"...which establishes a norm, and thereby allows hospitals to be rated and compared on a universally applied scale...which helps with insurance reimbursements, no doubt....and provides for sanctions if the hospital fails to comply with the "norm"...thus "helping to ensure quality of care"...at least in theory.

And yet....and yet I keep seeing all these instances in which the regulatory process has had a negative impact on "quality of care" in the place I work. And I've developed an actual list of "complaints" (imagine that) about JCHAO's impact on this particular establishment. Since, here on the Blog, carping is us, here's the list:

1. JCHAO is a business enterprise itself, and has a financial motive for making itself indispensible. It, therefore, finds new ways each year, to cause the system to alter itself to conform to a JCHAO priority thus making itself seem important. The hospitals aren't given a simple set of "must do"s that they can then achieve and maintain with a minimum of fuss and expense. Instead, each cycle brings a new regulation, new training, new paperwork; the old priority becomes unimportant (hardly anyone bothers about refrigerator temperatures these days...we got our thermomoters, our checklists, our instruction about proper temperatures...we're there and we've moved on...whatever the temperature is)... new year, new concern. Which is all well and good...but costs wads of money and time and, inevitably results in new forms to fill out and file and track. And all of it takes yet another slice out of patient care...which, ironically, is what it's designed to improve.
2. As I understand it, (and, as always, please correct me where I'm wrong...and don't just say "you're wrong" this time, tell me how it really is, please), the JCAHO inspection costs the hospital a rather large amount of money paid directly to JCAHO to do the job...i.e. we pay them to come in and regulate us. In off years we hire a consultant to tell us what JCHAO will be looking for next year and what we need to do to pass the next inspection...another chunk of money.
3. It costs huge amounts of staff time and attention to buff the place up prior to an inspection...charts are checked, floors are polished, talking points are reviewed, everyone is counselled to carry his/her hand sanitizor...tensions run high...and patients are an annoyance...continually interfering with our main agenda which is to pass the JCAHO inspection....again...so we can do it all over in a couple of years. And the line staff say, every year, "why are we doing this for JCHAO, when we don't do it for the patients?"
4. But my most insistent gripe is about the reglatory agencies' tendency to take charge of our patient's psychiatric treatment by dictating how things must be done, treatment wise. Telling a professional mental health staff what to do to help a particular patient or to manage a milieu, via regulation, prevents that staff from using its own educated judgement about what is best. The longer a staff is prevented from thinking on its own, the less professional it becomes, the less invested in the outcomes of its interventions, the more resentful in cases where the reguation results in damage to both patient and staff...

For example: JCAHO's regulation of the use of seclusion for psychiatric patients has resulted in a large reduction in the numer of seclusions in the hospital. And I agree that on the face of it, that sounds like a good thing.

To achieve this, there have been a number of JCAHO inspired behavior modification methods employed in recent years, to change staff's behavior about using seclusion as a treatment intervention or a mileau management strategy, including onerous paperwork and administrative oversight, staff re-education via lengthly training modules, etc. The lastest technique is to refer to a seclusion incident as a "treatment failure". Thus, with zero seclusions being the hospitals apparent goal, any incident during which a patient is secluded becomes a "treatment failure"...by definition.

Except sometimes it's actually good treatment to seclude a patient. In those cases, doing good treatment becomes a "treatment failure" resulting in sanctions against the treating staff by way of onerous paperwork and oversight. I can think of a couple recent examples of this good regulation gone bad . A developmentally delayed, psychotic patient impulsively grabbed another patient by the hair and punched her in the face. As the patient couldn't be secluded, he was "one-to-oned" - i.e. placed in an open seclusion room with staff sitting outside the door to constantly monitor his behavior. Days later, the patient continued to present a very significant assault risk, particularly to the staff who was assigned to the one-to-one. On one particular evening, the patient repeatedly attacked the staff, who repeatedly deflected the attack, until, finally in order to avoid injury to both staff and patient, the staff "closed the door"....the patient was secluded. Prior to this "treatment failure", staff had called the psychiatrist in charge of the patient who apparently advised "a back rub and a soda". This may have been the point at which the repeatedly attacked staff realized there was no relief on the horizon. He committed a treatment failure, in order to protect himself, the other patients and the patient himself from injury.
And I heard about a manic patient (different unit), wild and intrusive, coming up close, waving his hands in the air, babbeling tangential nonsense, loose on the unit who startled another mentally ill patient so badly that the patient backed up and fell, breaking both shoulder and hip... there was no "treatment failure" here since the manic patient was not secluded....yet...

How many assaults have there been since seclusion became a "treatment failure"? How many workmen's comp cases, how much time off, how many patients traumatized...is JCAHO counting that? How would those regulators know when the psychotic, out of control patient himself feels safer in seclusion? Why, exactly, is it better to let the patient assault or run amok than to seclude him/her? Treatment wise, I mean...and most of all, why isn't it the professional staff, hired to do the job, allowed to make those clinical decisions, based on the actual circumstances...isn't that why they were hired? Aren't they educated and experienced in just these matters? Isn't that, in fact, what they're getting paid for?

This phenomenon... the increase in patient-to-staff and patient-to-patient assaults as a result of the changes to seclusion regulations, is not confined to our hospital.
I know it's happening in other, similar hospitals, in other states. Psyc wards are increasingly dangerous places to work, or to be. Check the lists of "most dangerous jobs" sometime. Good psyc treatment requires a certain environment...it's best, for example, if the patients aren't under continual threat of assault...or the staff, either, for that matter.

To wrap this up, I think this is what happens when the regulatory agency has gotten too full of itself...it oversteps its mandate. There are things somebody should check on...cleanliness, malpractice, adequate staffing, etc. But when the oversight actually keeps staff from doing a good job, it's out of line.

Who regulates regulatory agencies?


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