16 Mar 1997
I just got back from the College of American Pathologists State Commissioners' meeting in Chicago, and the news is not good. Of course, there has been no good news from the CAP since CLIA '88, but this time the source of all the joy is a new overlord, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). It's as if Neville Chamberlain got summoned to Munich to get kicked around by Hitler a few times and then came home to rest, only to get called right back to face Mussolini.
"The Joint," as it is affectionately known, has demanded that the CAP, to maintain its all-important "deemed" status (by which CAP-inspected labs need not be inspected by JCAHO for the institution to have JCAHO accreditation), begin the comparative grading of laboratories. Accordingly, you will not get just a pass or a fail, as currently, but some type of score, possibly numerical. This information will be made public and could be used for marketing purposes.
The inspection process will take place as normal, and the system will be set up so that the inspector will go through the Checklists and answer "yes" and "no," just as now. The grade will be determined back at the main office, using a complex algorithm that will not be known to the inspectors, lab directors, or anyone outside of the CAP operation. I asked if this were like the IRS, and the answer was "yes." It will take several years for this whole thing to get up and running, but the JCAHO is determined we will do this, and the CAP is going to do it.
There are of course two big problems with this change in policy:
Of course, there are easy solutions to both problems. The first can be solved by getting rid of the volunteer inspectors and hiring a smaller number of full-time inspection teams, similar to what the JCAHO uses. The conflict of interest problem could be dealt with by not using practicing pathologists/lab owners as Commissioners. Both solutions would mean the end of true peer review in the CAP tradition, and the Commission on Lab Accreditation would become wholly redundant vis-a-vis the JCAHO.
The Chicago experience was my first physical meeting with the Lab Accreditation Program people. I can tell you that they are truly reasonable, good-humored, no-BS, practicing pathologists who only want to do good work. They are not out to "get" anyone. The problem is that the CAP's leadership position has been co-opted by CLIA '88, and now by JCAHO, and CAP is now stuck with fighting a wholly defensive war. Its Maslow's hierarchy has been chopped down to the lowest stratum, and its main effort now is just to survive.
My concern is that the CAP, like the young Anakin Skywalker, will start off with good intentions, and then fall victim, little by little, to the snapping dogs of expediency, to the point that the product will no longer resemble the raw stuff from which it was made, any more than Darth Vader resembled his son, Luke.
If the CAP completes its transmutation into nothing more than an enforcement agency for others, then new organizations will no doubt arise that will do what the CAP has supposed to have been doing all along: supporting the practice of laboratory medicine and pathology. This path has already been trod by the JCAHO. What started off as a collective effort to improve hospital quality grew into a bloated mass of bureaucracy that had a "we/they" relationship with its clients. Accordingly, new companies sprang up that specialized in helping the JCAHO's own clients get through one of its inspections.
I wish that the CAP Board of Governors would think about a change of direction. Why not tell HCFA and JCAHO to go do their own dirty work? Why not have the CAP fill in the role of support organization to its clients, who are trying to comply with the ever-changing demands of the regulators?
Would this mean a smaller,less powerful organization? Undoubtedly it would, but the decision to grow bigger and more powerful is not always the right one. We may have to have our meetings at the Holiday Inn and not the Ritz-Carlton, but we would be fulfilling the mission of the CAP, as set out a half-century ago.