Adding cost without adding value- baked into how we practice and the process measures we use

We recently went through a Joint Commission visit in one health system and mock visits in two other systems. The preparations leading up to these visits are remarkably resource intensive and without question divert resources from other activities which may be more valuable for patient care. We had one particular demand which was both silly and crazy at the same time. For reasons of privacy, we were instructed by our internal reviewer to turn all of our exam chairs such that a patient sitting in the chair could not be identified from the door. No matter that we have installed curtains which are pulled and block the view from an open door. No matter that the rooms were configured where the desk where the provider sits and documents when they are interviewing the patient will now afford the MD/PA a view of the back of the chair. No matter, our work and our opinions are beside the point.

If it were only that the Joint Commission were a bad actor but alas that is not the case. The practice of medicine is riddled with expensive and arbitrary practices which someone thinks might be a good idea and are implemented with limited if any evidence that they actually add value to patients lives. The value that might be added may be dwarfed by the actual cost of delivery.  However, it appears that no additional cost is ever viewed as excessive if it is borne by some other party and/or if the cost can be made sufficiently opaque. I spend my time taking training courses to maintain credentials, courses which impart questionable knowledge and assessed via tests which measure nothing of value pertaining to trivia which is quickly forgotten. On a regular basis, we participate in credentialing processes which remind me of the movie Men in Black. It appears that those involved have had their memories wiped on a regular basis forcing us to repeat steps which have been done over and over again over the course of literally decades.

Within the actual practice, we seem to be blind to the concept of diminishing returns. Any anecdote, no matter how rare or exceptional, can serve as a justification for some intervention which is pushed to be universally applied. The authority to hold people and systems to comply with such mandates tends to be delegated to regulatory entities which become interested primarily in perpetuation of their own existence and use their ability to publicly shame and operationally cripple health care delivery systems to force people and systems to kowtow to their demands, no matter how little value they add to patient care and how much cost is layered on.

There is little incentive to take on such regulatory entities. When you are under scrutiny, you would be crazy to challenge their authority. They hold all of the cards and while they may use such words as "partnership", don't be fooled. When you have finished the review process and met all of the demands, no matter how obscure, irrelevant, or trivial, the incentives drive you and your organization to get back to the work or your core missions. There is no clear pathway to hold the regulatory entities accountable and any effort to shine a light on the absurdity and arbitrariness of their work and rules will almost certainly come back to haunt your organization at the next review cycle.

This again brings to mind the quote from the movie "Bananas" -

Esposito: From this day on, the official language of San Marcos will be Swedish. Silence! In addition to that, all citizens will be required to change their underwear every half-hour. Underwear will be worn on the outside so we can check.