Tuesday, October 21, 2008

Joint Commission, are you listening?

I mourn for the demise of nursing care. I miss giving back massages, changing linens merely for comfort, sitting down to talk with people. I especially miss the value formerly placed on nursing measures as critical to quality health care.

Quality has been redefined to suit the criterion of measurability over any other. Now the ability to track standardized processes of care (not the outcomes necessarily) is the primary purpose of the medical record, and fluff like which position the person prefers for sleeping because of rib fractures and chronic back pain is devalued, and even discouraged. There is little room these days for individualization of care, which is where nursing has always excelled.

Because of the poor quality of its documentation of standardized processes, the hospital where I work is threatened with revocation of its Joint Commission approval - which means if our quality does not improve, we can't get Medicare reimbursement, and Medicare constitutes the major source of payment for any hospital. This could shut our doors.

Our Joint Commission status is "provisional," meaning if they show up and look around and find us wanting, we are history. To say our administrators are concerned would be like saying the KKK is concerned about the qualities of persons with enhanced dermal melanin content. Just doesn't quite capture the true spirit of the thing.

Pain management is one criterion on which our hospital was cited by Joint Commission. Certainly a worthy goal. The Joint Commission take on quality pain management requires that pain be quantified, treated, and re-assessed after treatment, and it follows that these elements must be documented such that they can be easily audited. Management has repeatedly stressed that nurses document these elements (not that nurses do these things.) Documentation is the only proof of adequate pain management that "The Joint" requires or desires. Indeed, our chief nurse executive informed us that one of the benefits of having computerized charting is that now she can tell who is documenting correctly and who is not - and disciplinary action can thus be taken. (Way to improve quality - threats!)

There is no evidence, unfortunately, that good documentation = good nursing care. There is nowhere to chart that, despite my giving the 71-year-old Cantonese-speaking lady more narcotic than was ordered, her pain was still a 7 out of 10. Nowhere to chart that her snoring respirations caused me enough concern that I was reluctant to increase her dose of narcotic further in spite of the pain she complained of whenever she was asked. Nowhere to chart that the non-verbal pain indicator scale did not concur with what she said when her son was there to translate. Nor is there anywhere to document that I spoke with the physician, who concurred with my plan. This is what quality nursing care looks like: letting her family remain at her bedside for comfort, judging cautiously how much narcotic to give and when, covering her with warm blankets when she was cold, believing what she said over the mandatory pain scale, wiping her forehead with a cool cloth when she vomited, speaking softly to her. But none of these actions is documented. None of them count.

The Joint doesn't know that these are quality nursing measures because they didn't even begin to ask nurses until 2003, when their first nurse advisory group was convened. The American Hospital Association and the American Medical Association have long been integral to the Joint Commission, but historically the American Nurses Association had been shut out.

There is hope: in 2008, one of the 13 Joint Commission officers is a nurse. In 2002, they released a white paper on the nursing shortage with recommendations for improving the supply of nurses. Some of the white paper covers what we already know: the shortage is unprecedented, people are aging, and nurses are crucial health care providers. Other parts of the report are insightful and action-oriented. The need for fiscal incentives to enhance nurse retention, ongoing education and federal funds for nursing enhancements in educational and health-care settings are plainly pointed out.

I am happy to conclude that "The Joint" is starting to get it, and I hope that one day they will stop to read all of what I put in my patient's chart and see how the individuality of each person informs my caring much more profoundly than a Joint Commission mandate ever could.

I will continue wiping foreheads and applying warm blankets. Perhaps there will be a time when such caring measures are also considered meaningful indicators of quality nursing care.

Sunday, October 5, 2008

College students are SO CUTE!

Salon magazine has a great article about Sarah Palin and the dumbing-down of the GOP (and America) here.

If this doesn't frighten you in preparation for Halloween, I don't know what will.

America has a long tradition of anti-intellectualism, borne, perhaps innocently, of trust in democracy, in the wisdom of the commoner, and the importance of hearing all voices in a country that strives for freedom. Or perhaps not. Maybe disdain for elitist smart people comes from a tragic belief that smart people are not like "us" (which means....hmmm...who? Dumb people?) Or maybe there's suspicion that well-groomed, college-educated, high achievers do not belong in positions of leadership in society. (Danger! Capable person in decision-making position! Danger!)

Even my adult, post-graduate university students, (whose admission GPA, by the way, hovers around 3.8) live under the delusion that utter equality is both achievable and desirable. Taken to the extreme, they think being equal (a noble ideal, to be sure) means being identical. It does not; it means celebrating the differences among us and not considering them signs of inferiority. It means providing for identical opportunities, not identical rewards.

Assigning grades is a notoriusly contentious example of the fine distinction between equality and identicality. Grading, some students believe, is akin to judging them on their score in a rigged game of dice. All who play, they say, deserve an A!

Forgive my ignorance, but who ever told you that college grades were a measure of how hard you worked?

The mistaking of semi-objective measures of achievement for global judgments of suitability, acceptability, (or just about any kind of ability) turns otherwise well-intentioned students into little monsters clawing at my office door, pleading for me to turn back time and to even out all the messy, random, unfair, individual disparities that forced them to mark choice C instead of choice A, as their best friend did.

"You didn't return all my papers on time, so I should get an A." "Other students had better clinical schedules; it is hard, you know, working and going to school. (So I should get an A.)" "None of the other professors gave me a B. (So I should get an A.)" "I was raised speaking another language. (So I should get an A.)" "Well, you know that I was sick during midterm. (So I should get an A.)"

One student actually asked me how she is expected to get the material if it's not written on the slides and she does not listen in class!

WHAAAAAAATTTTT??? Help, Lord!!! I am abandoned in the cruel and savage land of hostile non sequiturs!!!

---- several deep breaths later ----

Peppered with such nonsense from packs of hungry 20-somethings, foaming from mouths full of perfect teeth, what is a professor to do?

For one thing, we should admit it: tests stink as measures of mastery. In nursing practice, or any other profession/job/trade, your effectiveness has zero to do with your ability to sit in an uncomfortable seat and make the right marks on a worksheet surrounded by 40 other people doing precisely the same thing. Professors know this, but students don't, and (in another ugly fact) grades do count for things such as getting into the right graduate school.

There is no elegant solution to this dilemma, so I hope you haven't read this far hoping for one. This insuperable state is the sorry source of grade inflation, and no one's come up with a solution to that yet.

Not even the college-educated elitists.