Forgive my recent absence from our conversation. I plead a hectic week returning to work full of various unpleasantnesses; despondent trainees, dissatisfied journal editors, delinquent colleagues etc.
We've talked quite a bit, on occasion with no small amount of passion about the value and the downside of government regulation. Medicine provides an outstanding example of what you have been arguing for. The Joint Commission on Accreditation of Healthcare Organizations Hospitals (JCAHO prounonced "jake oh) began as an outgrowth of the American College of Surgeons attempt to produce a uniform set of standards for doctors and hospitals. In 1918, less than 15% of the nations hospitals met the first published set of standards. By the 50s (that blessed post war Ozzie and Harriet era) standards had improved dramatically and the joint commission offered hospitals a voluntary path to accreditation. In 1965, as part of Medicare, Congress accepted certification by the Joint Commission as a requirement for payment to hospitals participating in the program.
No one that I know questions the value and the necessity of JACHO, even though she is an annoying mistress to please. And yet (you knew this was coming), JACHO alone does not seem adequate to the task of providing adequate safety for patients. Hospital culture, like any culture, can be highly resistant to change. It took a series of repeated undercover visits by the state department of health and the threat of sanctions to improve hand washing rates at my hospital to an acceptable level.