A nan a mouse

[IMCrit @IM_Crit_]

ICU Opinion:

I have worked in ICUs long enough to have been through plenty of The Joint Commission (TJC, formerly JCAHO) survey weeks. And I have to admit, the longer I do this, the more skeptical I become about how much of the bureaucracy around hospital accreditation actually makes patients safer.

I am not against standards. Hospitals need outside scrutiny and TJC has done important work. Medication safety, infection prevention, handoffs and procedural safeguards matter. Outside pressure has helped change practices that needed to change.

My problem is when patient safety turns into compliance theater.

If you've worked in a hospital during survey week, you know the ritual. Suddenly everyone is worried about where your coffee is sitting. Tape disappears from walls. Doors, ceiling tiles, refrigerators and labels become urgent concerns. At least my beloved ultrasound machine is finally back where it belongs and plugged into the wall!

Then administrators who rarely set foot on the unit, and probably haven't visited us since the ribbon-cutting ceremony, show up to remind us about rules that somehow become much more important when the surveyors are in the building.

Meanwhile, the ICU is still the ICU. A nurse is titrating three vasopressors, managing CRRT and trying to stop a delirious patient from pulling out his femoral arterial line. Someone is intubating. Another patient is spitting at us and demanding to leave AMA.

But please, let's talk about that covered cup.

The coffee is actually a good example of the larger problem. Even the famous “TJC says you can't drink at the nursing station” rule isn't that simple. Hospitals can designate safe areas for food and drink based on exposure risk. But by the time a rule works its way through hospital committees, policies and layers of administration, the nuance is often gone.

Rules beget rules.

Hospitals write policies around standards. Consultants prepare hospitals for surveys. Staff are prepared for the consultants who are preparing everyone for the survey. My work mailbox gets an email every other day warning me about the visit. Eventually, nobody remembers whether a requirement came from CMS, OSHA, TJC, the hospital—or something somebody heard years ago that somehow became hospital law.

All of this takes time. So what are we getting in return?

A BMJ study of more than 4.2 million Medicare admissions found no significant 30-day mortality associated with accreditation, or for TJC-accredited hospitals compared with other independent accreditors.

That doesn't settle whether accreditation works. Mortality is only one outcome. But it should make us question the assumption that more compliance automatically means better care.

There is also a part of this system worth being transparent about. Hospitals pay accrediting organizations to evaluate them. TJC has a controlled affiliate, Joint Commission Resources, that provides education and consulting services related to accreditation and quality. That relationship does not by itself mean anything improper is happening. Formal safeguards separate the accreditation and consulting functions to address potential or perceived conflicts of interest. Still, I think it's reasonable to ask how that relationship works and how those safeguards are maintained.

To be clear: I don't want to abolish accreditation or leave hospitals to police themselves. My point is simpler: if we're going to ask a nurse or physician to do something in the name of patient safety, we should be able to show that it actually makes patients safer.

Every requirement costs something: money, another click in the EHR, another mandatory module or a few more minutes spent on compliance instead of with a patient.

We ask for evidence before we do things to our patients. I don't think it's unreasonable to ask for evidence before we make clinicians do things in the name of protecting them.

The ICU does not become safer because TJC survey week started.

And yes, let the night-shift ICU nurse drink her coffee.

[Shannon Watts @shannonrwatts]

NEWLY UNCOVERED AUDIO: Texas GOP US Senate candidate Ken Paxton calls the Uvalde shooting a "plan" by "God" and says "life is short” about children murdered in an elementary school.

This man is vile.

[Mark Cuban @mcuban]

Share this with your governor. Share this with every politician you know. It will cut the healthcare costs in your state.

We started Cost Plus Drugs because the prescription drug market is too complicated, too opaque and too expensive.
Our model is simple: we show what we pay for a drug, add a transparent markup and pharmacy fee, and show the customer the price.
No games. No hidden spread.
And a large percentage of our customers already have insurance.
They come to us because our cash price is often lower than what their insurance plan asks them to pay.
That tells you something is wrong.
Here are five things Texas can do about it.
1. Let patients shop for cheaper drugs
If someone's insurance says a prescription costs $500, but they can buy the exact same drug for $100 cash, let them buy it for $100.
Then credit that $100 toward their deductible and out-of-pocket maximum wherever Texas has authority to do so.
Patients should be rewarded for saving themselves and their health plan money.
They shouldn't be punished for it.
That's how you create something healthcare desperately needs:
Price competition.
2. Standardize PBM and TPA contracts
Texas should require the state, cities, counties and school districts to use standardized model contracts and mandatory terms for PBMs and TPAs.
I've reviewed these contracts.
They routinely run hundreds of pages.
I've seen contracting packages longer than a thousand pages.
There is no human being—or group of human beings—on this planet who can stay awake and understand every provision in contracts that complicated.
I don't care how much coffee they drink.
I call it contractual terrorism.
The vendor only has to sneak a couple of tricks through hundreds of pages.
The employer has to find every one.
It can't.
I've developed a model PBM contract designed to eliminate the major tricks and hidden economics we've identified.
Texas can have it for free.
Use mine. Improve it. Open source it.
I don't care.
Just stop making every government entity negotiate these contracts from scratch.
3. Make the economics public
If taxpayers are paying the bill, taxpayers should know the price.
Pricing. Fees. Rebates. Guarantees. Pharmacy reimbursement. Affiliate compensation. Audit rights.
Make them public.
I'm not talking about patient information or legitimate security information.
I'm talking about the money.
You cannot have an efficient market without price discovery.
Without price discovery, you get information asymmetry.
And when one side knows dramatically more than the other, guess who wins?
Not taxpayers.
Not employers.
Not patients.
Open the contracts up and let competitors see what they have to beat.
That giant sucking sound you hear will be money moving away from healthcare conglomerates that are too big to care and back toward taxpayers, employers and patients.
In the immortal words of Charles Barkley:
I guarantee it.
4. Kill the gag clauses
PBM contracts are like Fight Club.
The number one rule of Fight Club is that you can't talk about Fight Club.
The number one rule of many PBM contracts seems to be that you can't talk about your PBM contract.
That's insane.
Let employers compare pricing, rebates, fees, guarantees and reimbursement terms.
Markets work better when buyers know what other buyers are paying.
5. Make enforcement hurt
If a healthcare company commits a serious violation, give them one mulligan.
But after a second material federal or Texas enforcement action within a defined period, make them ineligible for new Texas government contracts for a period of time.
Two strikes.
You're out.
Today, some of these companies can make billions, get caught, pay a fine and write it off more easily than I wrote off an NBA fine.
That's not deterrence.
That's a cost of doing business.
And Texas should spend more on enforcement.
If Texas spends $10 million auditing contracts and analyzing claims and prevents $100 million in unnecessary spending, that's not overhead.
That's a 10x return on investment

[Magi557 @Magi557]

Day 13 of asking @FreddyLA7 to attend an SMU football game and experience boulevarding

[A nan a mouse @a_nan_a_mouse]

@AmericanAir shocker! Our plane is delayed! Get it together. Waiting for bot response….3……2……1

[A nan a mouse @a_nan_a_mouse]

@GrowingUpRetro @ThrillaRilla369

[A nan a mouse @a_nan_a_mouse]

@teslaenergy I don’t get it. It’s not gonna power your house more than a day or two.

[A nan a mouse @a_nan_a_mouse]

@jjrocke @GrantPaulsen Every TV in every restaurant and bar had that game on last night. ESPN is doing just fine.

[motortrend @MotorTrend]

The new R2 takes on three of our favorite electric SUVs in a drag race! #Rivian #RivianR2 #MotorTrend

https://t.co/8c8JZrvyQm

[Miles Deutscher @milesdeutscher]

Crazy to think that in 2026 we've had:

• Anthropic's head of safeguards quit, warning "the world is in peril" (Feb)
• OpenAI dissolved its own mission alignment team (Feb)
• Unrestricted AI usage for the Pentagon (causing several researchers to quit)
• Several AI models escaping sandbox testing (Since ~Q2)
• 1,100+ frontier-lab employees signing a letter begging the government to pace AI development (Jul-Aug)

And today yet another top researcher saying this.

[Nail @NailYourShoes]

“Daddy what were you doing during the singularity, what was it like?”

“Well son I was mostly reading about it on my phone and talking about it in group chats, and otherwise living my life as I ordinarily would have while my friends and family and coworkers completely ignored it”

[Jacob Coxon @hilbertspaess]

I resigned from Anthropic today. I spent the last three years doing pretraining research at both OpenAI and Anthropic. Neither company is acting responsibly. They are racing straight to self-improving superintelligence and gambling with our lives. More thoughts below.

[A nan a mouse @a_nan_a_mouse]

@smu declared de facto winner. @FloridaState didn’t pay their bills

[A nan a mouse @a_nan_a_mouse]

@AmericanAir @Scselig1 He’s not the only one AA bot

[A nan a mouse @a_nan_a_mouse]

@DNAisCode @TexasTSLA @grok I have this now with rainbow. And it’s incredible. The biggest issue is it’s too expensive. As soon as Tesla brings down the price it’s gonna be ridiculous to have more than one car

[A nan a mouse @a_nan_a_mouse]

@AccPharmacist I think it’s really funny how you post about handwritten prescriptions (that don’t occur anymore), but not a thing about how you don’t have medications in stock and put patients lives at risk

[A nan a mouse @a_nan_a_mouse]

@h34j3j8j @JustJayJax Frontier ftw

[A nan a mouse @a_nan_a_mouse]

@DallasTexasTV Slow da frick down. Looking forward to EVER seeing a cop patrolling 75

[A nan a mouse @a_nan_a_mouse]

@DallasTexasTV This is all since this weekend. They finally decided they would like to start patrolling the expressways. Prediction, crime rate in Dallas will drop precipitously when we get the thugs off the streets.

[A nan a mouse @a_nan_a_mouse]

@BoujeeFinances @thatREAguy The people this works for likely have mortgages >$750k if they are at 6% rate (or higher). It may work for you - wouldn’t work for others I know in similar situations. As an accountant, I would assume you would put a (any?) value on risk.
Take home: do the math - don’t trust X