Finally, a ruefully unsatisfying bit comes from an evaluation of The Joint Commission on Accreditation of Healthcare Organizations measures.⁴ The Joint Commission, functioning in the U.S. as a bit of a de facto quality-enforcement body, generally requires measure compliance as a result of the financial impact associated with potentially losing accreditation. The Joint Commission standards reports, also known as R3, “requirement, rationale and reference,” describe the evidence in support of their actionable standards. Breaking down the 20 actionable standards with 76 distinct components, the authors found only six were completely supported by cited references. Upon evaluating the quality of the evidence, the authors found only one of those six supported by GRADE level B evidence, while the remainder were GRADE level D: “very low”. While these standards may indeed reflect high-quality medical practice and improved outcomes for patients, it is clear compliance may also ultimately represent unsupported, low-value investment. 

In summary, much of our current clinical practice remains prone to medical reversal and the guidelines upon which we base our practice rely on low-quality evidence, as do the standard measures enforced for hospital accreditation. While this may seem cause for despair, the better lens through which to view these limitations is humility. While emergency physicians continue to work to provide the best care possible for patients, we must recognize and embrace that change is inevitable. 

 References 

1. Brown J, Lane A, Cooper C, Vassar M. The results of randomized controlled trials in emergency medicine are frequently fragile. Ann Emerg Med. 2019;73(6):565-576. 
2. Parish AJ, Yuan DMK, Raggi JR, Omotoso OO, West JR, Ioannidis JPA. An umbrella review of effect size, bias, and power across meta‐analyses in emergency medicine. Academic Emergency Medicine. 2021;28(12):1379-1388. 
3. Fanaroff AC, Califf RM, Windecker S, Smith SC, Lopes RD. Levels of evidence supporting American College of Cardiology/American Heart Association and European Society of Cardiology guidelines, 2008-2018. JAMA. 2019;321(11):1069. 
4. Ibrahim SA, Reynolds KA, Poon E, Alam M. The evidence base for US Joint Commission hospital accreditation standards: cross sectional study. BMJ. 2022:e063064. doi: 10.1136/bmj-2020-063064. Available online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9215261. Accessed October 9, 2022.