Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Zero Tolerance For Bad Behavior

TJC/JCAHO (The Joint Commission/the Joint Commission for Accrediting Healthcare Organizations) decided that it would expand its influence in hospitals. While the problem they address is real, their solutions are as unrealistic as ever.

According to this study, their results may match their logic – negligible. Or were things that much worse before JCAHO/TJC became involved? It is hard to believe that anything improves with them. Maybe they justify their behavior with the myth that in spite of being a mass murderer, at least Hitler Mussolini made the trains run on time.[1]

The survey comes almost one year after the Joint Commission began requiring health care facilities to implement zero-tolerance policies that define intimidating and disruptive behaviors. The commission also required that facilities establish disciplinary procedures for medical staff and other health care professionals who violate the standards.[2]

What does Zero Tolerance mean?

How little is required to get a doctor’s privileges suspended?

How little is required to get a nurse fired?

Imagine if this were applied to EMS. I know of several medics who might not make it through the week without indulging in all of these misbehaviors. Some agencies do not seem to believe that medics should talk to EMTs at less than 80 decibels, unless they make up for it with gratuitous projectile spittle.

Is there to be a specific decibel level that is measured? There are decibel monitors at some nurses’ stations already. If JCAHO/TJC were to run this, they would probably require a deafening alarm that would be activated above a certain decibel level.

The real reason the hospital is so noisy, is to drown out the sound of all of the alarms going off. If anybody were aware the alarms, they might feel the need to do something about the alarms – such as hit the silence for 2 minutes button.

Degrading comments and insults … 84.5%
Yelling … 73.3%
Cursing … 49.4%
Inappropriate joking … 45.5%
Refusing to work with a colleague … 38.4%
Refusing to speak to a colleague … 34.3%
Trying to get someone unjustly disciplined … 32.3%
Throwing objects … 18.9%
Trying to get someone unjustly fired … 18.6%
Spreading malicious rumors … 17.1%
Sexual harassment … 13.4%
Physical assault … 2.8%
Other … 10%

Just think of the benefit to those trying to get someone unjustly disciplined or unjustly fired. Now they will have more excuses to document as justification for their misbehavior.

The AMA developed a policy model that calls for distinguishing between good-faith criticisms and actions that truly rise to the level of disruptive behavior, and for implementing fair medical staff review processes.

Paul M. Schyve, MD, senior vice president of the Joint Commission, agreed there are appropriate moments for speaking up. But he said the ACPE survey findings highlight types of behaviors that exceed constructive criticism, and if left unchecked, can inhibit others and ultimately can undermine patient care. “We can’t let the little things slip.”

Don’t worry. We do not intend to have anyone punished for constructive criticism. Just remember that we decide what is constructive – and we are intolerant of anything that might be disruptive.

Will it be considered disruptive to criticize this policy? Clearly, if TJC/JCAHO states that this policy will make things better, then criticizing the policy is an example of exactly what they are trying to stop. As Dr. Schyve let slip –

“We can’t let the little things slip.”

TJC/JCAHO has repeatedly demonstrated that they are all about the little things.

The problem with JCAHO/TJC is that they end up paying more attention to the enforcement, than to the actual problem. They look for rules that will be very sensitive, while ignoring the greater need to be very selective.

Inappropriate joking?

I can’t even mention JCAHO/TJC without the use of inappropriate joking. Of course, I do not see it as inappropriate, but I do not make the rules. Those making inappropriate rules will determine what is appropriate. They might consider this post to be a malicious rumor, as well.

Zero Tolerance should not be tolerated.

If we are going to have any JCAHO/TJC Zero Tolerance policies, the policy should be to ban all of their people from health care facilities. We should not tolerate their counterproductive rules. I really would not want this to be a Zero Tolerance policy, since they are foolish (both the policies and JCAHO/TJC), and because even a blind administrative nut might find something that is not completely squirrelly within all of its plotting.


^ 1 Did Mussolini make the trains run on time?

^ 2 Disruptive behavior by doctors, nurses persists a year after crackdown
A survey of physician and nurse executives raises questions on how to implement zero-tolerance policies required by the Joint Commission.

By Amy Lynn Sorrel, amednews staff.
Posted Nov. 16, 2009.