Hospitals In Focus

The Impact of AI and Environmental Sustainability on Hospital Care


Dr. Jonathan Perlin, President and CEO, The Joint Commission  


The Joint Commission is possibly the most impactful health care quality and performance organization in the world. With the rise of AI and concerns growing over issues like environmental sustainability, its mission has never been more critical. 

Dr. Jonathan Perlin, in his second year at the helm of The Joint Commission, is on a quest to reshape safety and performance measurement and its impact on care delivery for hospitals and other settings. 

In this episode, Dr. Perlin outlines his H.E.L.P agenda and explains how the acronym is a guide for the organization as it aims to better ensure patients’ safety and effective hospital care. 

H.E.L.P Agenda includes:  

  • Health Equity 
  • Environmental Sustainability   
  • Learning Health Care/AI 
  • Performance Improvement and Integration   


The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. 

It aims to accomplish this goal by setting quality standards, evaluating an organization’s performance, and providing an interactive educative experience that provides innovative solutions and resources to support continuous improvement. 

Learn more here: https://www.jointcommission.org 

Speaker 1 (00:05):

Welcome to Hospitals In Focus from the Federation of American Hospitals. Here’s your host, Chip Khan.

Chip Kahn (00:16):

Hello and welcome to Hospitals In Focus We so appreciate you listening. Since its inception almost 75 years ago, the Joint Commission has become possibly the most impactful healthcare quality and performance organization in the world. And for the last two years, it has had new leadership with Dr. John Perlin at the helm. John is on a quest to reshape safety and performance measurement and its effect on care delivery for hospitals and other settings. His task is not a simple one with the complexity of hospital care today, rapid technological advancements, and the advent of generative AI. He joins us to talk about these topics as well as outline the organization’s priorities for the future and how he hopes to better ensure patient safety and effective care. John, thanks so much for joining us today.

Dr. Jonathan Perlin (01:12):

Chip, it’s a delight to be with you. Thanks for the opportunity.

Chip Kahn (01:15):

John. Just to get started, let’s talk about the current role and mission of the Joint Commission. What have you set out for your immediate goals considering the historical role that the Joint Commission has and the role that you think it should have in through the future?

Dr. Jonathan Perlin (01:33):

Well, the Joint Commission is a venerable organization. Its current format is 75 years old. And its roots actually traced back to the turn of the 20th century to Ernest Codman’s work. When Ernest Codman set up the American College of Surgeons, he and his colleagues had a revelation that healthcare was changing. It was much more technical. And that hospitals had to be prepared to deliver more technical care with the tools and equipment necessary. But there was no one to inspect that. As you might imagine in the early 1900s, 1913, to be precise, what were called hospitals varied greatly. American College of Surgeons inspected those organizations until World War II. In fact, many note that physicians largely ran hospitals until World War II. Of course, they were drafted to serve us. In their absence, the ascension of professional management occurred.


And after World War II, there simply weren’t physicians to do the inspections. And the American College of Surgeons went to other organizations, namely the American Hospital Association, the American Medical Association, the American College of Physicians, and the American Dental Association, and jointly established a new entity to inspect healthcare organizations to make sure they had state-of-the-art equipment. When you go forward to 1965 and the advent of Medicare, the Joint Commission’s role was actually memorialized in statute where it would become an arm for CMS to assure accountability. But in its most contemporary invocation, we have really two roles. There’s a public trust and accountability that derives directly from the mandate that we have from CMS. We are an agent of CMS to inspect. However, any of us who’ve been involved in quality know that you can’t inspect quality into a process. We know that inspection will only allow a process to perform as well as it’s designed.


And so, the other half of the Joint Commission in its current conception is really less of guard dog and more of guide dog. It’s working with organizations to really elevate care, to understand how things happen that lead to adverse events and improve safety, and importantly, to understand why things work and elevate quality. And it does so of course today, not just in the hospital but across the continuum of services. But that’s the history of the Joint Commission. And I’d be delighted to talk to you about our current agenda since I’ve been there.

Chip Kahn (04:02):

Well, let’s go to your agenda. And I think you have coined it as the HELP agenda. So, one, can you tell us what HELP stands for and how you perceive it, and then maybe also give us some sense of where you think you’ve come over the last 24 months since you’ve, as I said, been at the helm of the Joint Commission.

Dr. Jonathan Perlin (04:24):

Well, thanks, Chip. Exactly right. HELP is an acronym for Health equity, Environmental sustainability, Learning and really AI and how that’s changing healthcare, and Peak, performance improvement and integration. Let me just walk down those letters sequentially. I came to the Joint Commission from operations, of course, my role as president of clinical operations and chief medical officer at HCA. By the time I left HCA, we had cared for over 400,000 COVID positive inpatients. And so, the challenges of the height of COVID is not theoretical to me. It wasn’t a public health experiment. It was real life. Each and every other day, we saw the dislocations to individuals not having the systematic services they needed and the exacerbation of well-known disparities, things frankly that our organization had made a lot of progress on, including things like maternal mortality. We saw women not getting services in their community that were desperately needed.


So, given the opportunity to address health equity at the Joint Commission, it was an opportunity not to be best. I think Martin Luther King said it best 70 years ago, of all the forms of inequality, injustice and health is the most shocking and inhuman because it often results in physical death. And the truth is sadly, that observation was also a prognostication. Even today, Black and African-American patients experience an age adjusted death rate that’s twice that of white using the OMB nomenclature, American Indian, Alaskan Natives experience age adjusted mortality rate that is even higher. And so, we have major problems. Just to put a finder point on it, these aren’t just issues of social justice or health justice. They’re issues fundamentally of patient safety. They’re issues of access, but there are also financial issues.


The adverse outcomes associated with disparities cost our country an excess of nearly $350 billion today according to Deloitte. And that will go up to a full trillion dollars a year by 2040 if we don’t address them. And so, we introduced a few mechanisms to our agenda. We introduced a new standard that became a national patient safety goal for addressing health equity. It has six components. Designate a leader to look at your own data, assess health related social needs of your patient base, stratify your own quality and safety data, identify an opportunity and create an action plan, engage on improvement, and keep stakeholders reform rates and repeat. So, what’s notable is that unlike previous standards, we didn’t stay focused on transportation or medication, or things that were really beyond the healthcare organization to solve in the community. Look at your own data. Maybe it’s patient experience. Maybe it’s healthcare associated infections. Maybe it’s maternal mortality. Take note of your own data and engage. If there are no problems, great, that’s pretty rare. But if there are opportunities, what a tremendous opportunity to make a difference.


And what’s also notable about this is that in approaching this way, we wanted the standards to be less performative, less prescriptive, and more integrated with an organization’s own operation. So, we’re beginning to quantify the impact and we’re really excited about some of the additional work. There’s also launched midyear in ’23 was a voluntary advanced certification in healthcare equity. The entire Commonwealth of Massachusetts engaged on this as a basis for their 1115 Medicaid waiver. And pleased to say every hospital in Massachusetts made progress toward that in 2023. There’s being some things written about that now, including some information that’s up on the Massachusetts Hospital Association website. Let me turn to the E in the HELP acronym, environmental sustainability. I defy any healthcare organization to not have a mission that doesn’t speak to doing good for others, for doing good for their community. But as a completely unintended consequence of our activity, we’re actually doing harm in terms of the environment worldwide.


Healthcare is, if in the aggregate, would be the fifth most polluting country. And among all countries, there’s none that makes more pollution in healthcare than the United States. We’re 27% of the worldwide healthcare carbon footprint. And in the United States, we’re about 9% of the carbon footprint overall. And so, we have an opportunity, but this is also a very practical opportunity. Despite the fact that all of us, whether we’re in New York, or Chicago, or even as far south of Florida, we all smelled the smoke of Canadian wildfires. We all watched the torrential flooding in Montpelier, Vermont that actually flooded out the Vermont Hospital Association. 14 feet of snow in Northern California, red side around the Gulf Coast on both sides of Florida on the west coast as well. And so, it’s in front of us. We’ve got to do something. Our younger colleagues are demanding attention to this.


A couple of weeks ago, the Commonwealth Fund just put forward a new report that found that 80% of health professionals wanted their healthcare organizations to address environmental sustainability. And the Robert Half Company identified that workers between 18 and 34 did not want to work for organizations that did not have a sustainability commitment. And so, if on every health executive’s top five issues as workforce, workforce, finance, finance, and patient disposition, then right at the top of that is an opportunity to really engage with health workers who want their organizations to attend to sustainability. I know as a parent of mid 20s, older 20s age kids, they’re very attuned to this. Their friends have conversations about even not wanting to have children by virtue of environmental threat. And so, for young workers, this is front and center on their mind. And trust me, it’s rare that you go out to healthcare organizations and folks ask for standards. They usually ask for less standards, and I’ll come to that momentarily. But they’re asking for standards and sustainability.


And in terms of workforce, this is a great way to engage, and retain, and even recruit healthcare workers. And by the federal incentives, allow direct cash payments to entities that don’t pay taxes. And for tax paying entities, tax credits for any work that’s initiated before 2025. The Ohio Hospital Association is a great resource. They have a consulting branch to help organizations take advantage of those incentives. As we come to the L in the HELP acronym, really talking about learning, and that stands for AI. Every Conversation Healthcare is about how we improve the safety quality, efficiency, effectiveness, access equity through the use of these new AI tools. But it all starts with the responsible use of health data, which is the name of our new voluntary certification that began at the first of this year.


It begins with use or what’s called the secondary use of data. Data are created for clinical purposes. Someone gets a blood test from me, they look at that blood test, and then fulfill this clinical purpose. But those data in the aggregate allow us to gain insights into healthcare operations, and to quality, and to safety. And we want to make sure that when we use these data, that we use those data responsibly. And so, we took notes of the great work done over a number of years by Health Evolution and put together a framework for guiding the safe and responsible use of secondary health data. It includes a process to assure or validation of an organization’s processes for de-identification, for data controls or privacy, for limitations on use. So, an organization doesn’t inadvertently find that a partner has reused those data, for validating algorithms for transparency to the patient, and an organization’s own internal governance or oversight structure.


I live between two fears. The fear on the one hand is that we do bad things and we’ve seen some bad examples of training algorithms on data that includes disparate outcomes and reinforcing disparities. Not the intent, but my bigger fear is on the other side. My bigger fear is that in the absence of self-governance, we invite stifling overregulation. And that would be terrible. In my alma mater HCA healthcare, we put together an algorithm to detect sepsis. And on top of already benchmark performance by using this algorithm in just 18 months, 8,000 additional lives were saved. The computer can see things faster than humans do. And what a shame to miss these extraordinary opportunities to allow individuals to celebrate a birthday, welcome a new year, welcome a grandchild, or just remain a vital part of a family or a workplace or a social structure.


So, we need to use these tools. And I would have liked to have had the external underwriters’ laboratory to say, “Hey, we’re doing things right in terms of protecting the interest of patients in a way that’s publicly defensible.” Let’s now turn to the P, which is performance improvement and integration. We know that regulatory burden is incredibly frustrating to care providers and administrators alike. And so, since I’ve been at the Joint Commission, and I’m pleased to say that we have eliminated 400 standards that are redundant, obsolete, not evidence-based or where the effort’s simply disproportionate to the value that’s generated. Instead, we only have one new requirement that’s the health equity standard.


We have three new voluntary opportunities, the advanced certification and healthcare equity. We have the sustainable healthcare certification, which by the way is a virtual and done at costs so that all organizations that want to engage can participate in that. And we have what I just mentioned, the responsible use of health data certification to allow organizations to assess their own processes, to be sure that they have as great integrity as possible and stand public scrutiny in the use of secondary data and the generation of algorithms. So, I also mentioned that with the health equity accreditation requirements, it was directional. It wasn’t prescriptive. We saw a lot of deterioration in quality during COVID. And to my eye, what that means is that too much of what we’re doing was really performative for a survey. We don’t want to burden you with performative activities. We want to engage with healthcare organizations, and really taking things that they want to do, and integrating it into their day-to-day operations. And there are some things that the conditions of participation, which we’re required to survey to simply don’t cover.


Give you an example. Workplace violence. Sadly, violence and healthcare workplace is not sevenfold from pre-COVID. And our standards, our above and beyond standards include guidance on a safe and healthy workplace. We want to provide air cover for organizations to do what’s necessary to assure that their staff, that patients themselves, and visitors enter into an environment that’s physically and psychologically safe, and that those organizations feel that they have full backing of the Joint Commission in terms of setting behavioral expectations and increasingly volatile environment. So, that’s our health agenda in a nutshell. Health equity, environmental sustainability, learning healthcare, really setting the stage for self-governed AI and performance integration to reduce the theater of survey activity and really increase the support for things that are meaningfully integrated into an organization’s own operations strategy.

Chip Kahn (16:22):

It’s an impressive agenda, John. And for everything I know, I think you’re hitting on the important themes of the day. But each of those calls on an action agenda for hospitals that are caring for patients. And you brought up in your introduction to this, the issues of economics and workforce. I mean making the enterprise of the hospital care possible and sustainable with all of these heavy new expectations. So, let me do a little bit deeper dive, and I’m going to ask a question on each of these items that you point to. And it seems to me that the two issues that are critical for hospitals here is in terms of the Joint Commission is one, you have a goal, you have a mission, you have a framework for hospitals, but where are the real expectations? And you bring it up in the words you use regarding burden reduction. But I’ll just talk about expectations regarding balance.


And so, let’s start with equity. Because it seems to me when you talk about having to look at your data and see how you’re literally treating patients, that if we think of the sort of Maslow’s pyramid, that’s the minimum. Are you treating everyone appropriately and the same who have comparable conditions? But this issue of social determinants is a much bigger issue. Where, regarding the four walls of the hospital, do you think in terms of your expectation, the hospital role is defined? And where is the community and others responsible for making sure that the total health individuals who suffer from these disparities who were more vulnerable to COVID, which just exposed so much of this differentiation in our society that goes way beyond the healthcare system? Where do you draw the line in terms of what a hospital CEO needs to have as an expectation from the Joint Commission that they’re going to take responsibility for to ultimately, hopefully eradicate to the extent that they can these disparities?

Dr. Jonathan Perlin (18:46):

Great question. And first, let me just applaud healthcare organizations that are doing more than is their mandate. Within the walls of the healthcare organization, you need to make sure that all patients are being treated equally and appropriately. Whether it’s the patients on ward 4D versus 4C. Or whether it’s patients of color versus white patients. Or whether it’s elderly versus young. Those are just things that any responsible health executive wants to know. But you’re absolutely right, Chip. There are adverse determinants that have led to disparities in our society. They’re well beyond the purview of the hospital. And the hospital though is an anchor in the community. And those issues are so complex that they’re best addressed through partnerships with community organizations, through partnerships with government. Of course, the hospital is major social organization in that, but it’s the singular answer and it never can be.


And I think that’s one of the things that’s quite challenging for hospitals. We see it, for example, in the area of behavioral health when all other pathways fail where those patients end up, they end up at the hospital and they end up boarding the emergency department, the community turns to the hospital and says, “Hey, you solve it.” Well, I know this is a tough thing to acknowledge, but that’s a broader societal issue. And we really need to compel conversations with community organizations, with social service organizations, with our governmental leaders at every level of government to solve problems that are bigger than the healthcare organization.


But within our walls, that’s us. That’s where we have to be sure that, why does one population have a higher rate of hospital acquired infections and surgical site infections? And I’m not saying that in the abstraction, I’ve looked at data from healthcare organizations all around the country. And even adjusting for comorbidity, there are differences that are not explainable on a clinical basis. And that’s our responsibility as healthcare organizations. And that’s where the Joint Commission sees its remit. We are not asking organizations to solve society’s hills writ large. We’re asking to partner with organizations in making cure better within the healthcare context.

Chip Kahn (21:00):

And let’s get specific too on the environmental aspect. Because I know years ago, and part of this was outside the hospital, there was a crisis in the sterilization of instruments and devices because the company that did a great deal of it was a big polluter. But on the other hand, they made the argument that there really was only so much technology available to them. And at the end of the day, you’ve got to have sterile instruments. You’ve got to have sterile devices because that’s just critical path to safety in hospital care.


So, we’ve got these issues like that. And then also we have plants across the country in hospitals that vary in age. And clearly these issues, this issue of carbon footprint is partly defined in terms of where your plant is regarding its history. Because the older the plant, probably the higher the emissions because of the physical vehicles you use to take care of those. What’s your expectation there? What is the framework that hospital CEOs, getting back to that CEO, is going to have to deal with when the inspectors walk through the door and say, “We have an expectation on environment?”

Dr. Jonathan Perlin (22:29):

So, first off, let me just reinforce that the sustainability of the certification, it’s voluntary. We think it’s very worthwhile as an organizing opportunity to address sustainability, which attaches to your workforce recruitment, retention, and also helps align forces for tapping into the IRA, the federal incentives to help address aged and inefficient infrastructure. It’s really pretty easy. It’s have a strategic plan, vet it with the board, identify three of six suggested opportunities for improving emissions, engage on improvement efforts, take stock of your performance, rinse and repeat. So, it’s very, very straightforward. Now, behind your question is what can we really do in healthcare? And so, let’s look at the sources of how healthcare generates an excess or outsized carbon footprint. And I didn’t know a lot about the impact of healthcare on the environment until I began to work with Victor Dzau National Academy of Medicine on the National Academy’s Action Collaborative on Decarbonizing Healthcare.


So, I mentioned that if healthcare worldwide where country would be the 5th biggest polluter, it’s 9% of our US footprint. There are a few things. First, let’s talk about resilience and being there in times need. Did you know that according to the T.S Chan School of Public Health, 81% of primary care clinics, 81% were closed for at least one day in the last three years because of an extreme weather event directly attributable climate change? Because we weren’t there when our communities needed us most. Those incentive dollars can be used to make our facilities more resilient. I’ve already mentioned the interest of younger workers and having sustainability. But let’s now dive into what creates pollution. And there are typically described three scopes. And just simplifying the technical language, the stuff we do, the stuff we burned, power, our buildings and vehicles and the stuff we buy.


Now, the stuff we do is a really libert area because while it’s only 7% of the pollution stack, the chemicals that we use for anesthesia and a meter dose inhaler are 1,600 to 3,600 times more warming than carbon dioxide. So, meter dose inhalers are about half of that. They still use propellants that we outlawed because of damage to the ozone layer 30 years ago and everything else. Now we’re taking a slow process to transition over to what are called breth powered, B-R-E-T-H, breth powered or dry powdered inhalers. And that’s going to take some time to transition, but we can eliminate that source of pollution. The other is that there are three or four agents that we use anesthesia that are problematic. Isofluorine and desflurane, fluorinated hydrocarbons. Typically, we just turn it on with a high fresh gas flow rates and a lot of that stuff goes right by the patient and out into the atmosphere.


Simple fix, turn down the flow rate. Kaiser Permanente did that and save $20 million in one year just by turning down the flow rate, much less pollution. Ideally, you don’t even use those gases. Disperse program at the University of Washington, Seattle Children’s Hospital absolutely eliminated these gaps entirely. Nitrous oxide turns out to be another offender. Some of our, as you mentioned, infrastructure is pretty aged and the pipes are leaking. And so, if you just go to using a tank at the patient, then you have much less nitrous oxide that’s poured into the atmosphere. And again, that 7% is 1,600 to 3,600 times more warming than carbon dioxide. So, a big opportunity in things that we have direct control over. The next 11% are our physical plants. Very different for agent infrastructure in the Northeast than it is for new infrastructure and somewhere that’s pretty temperate. But this is where those incentives are so valuable.


If someone offered you the opportunity to recapitalize the infrastructure of the HVAC, the windows, the lighting in your house with funds that would make the ROI about 18 and up more than 24 months, I mean, the answer would be an easy yes. We’re talking capital dollars. And I fully get that organizations are under incredible operating strain. But after that 18 to 24 months, those savings can be plowed back into operations. So, this is a once in a lifetime, unprecedented, not to be missed opportunity. And even older organizations have found some simpler fixes. Memorial Sloan Kettering in Midtown Manhattan put awnings on its windows and cut its some heat or air conditioning bill by 30%. Cleveland Clinic has saved $20,000 per hour per year in turning down the cycle exchanges of the HVAC system and reprocessing instruments going to LED lighting. Ronald Reagan Medical Center at UCLA saved a million dollars a year and in the aggregate has now saved 300 tons of trash by switching from disposable to long, durable surgical gowns, no difference in terms of infection risk.


And that leads us to bucket three, and this is obviously the big one. 82% is the stuff we consume. Did you know that for every a 100 beds in a hospital, a ton of garbage is created and 15% of that may be infectious, sharp, dangerous, toxic, radioactive, et cetera? And this is an area where we can clearly can improve through the use of reprocessing of materials. We actually invited Joint Commissions, harshest critics in to make sure that there was no inadvertent implication that disposable or single use was any better than things that could be used multiple times instead. And we want to be very science driven in this area. And there’s a huge amount of opportunity, but there’s also a huge amount of policy work that needs to occur. Imagine if you could go into your list of material supplies that you’re obtaining and have by the line item, the carbon footprint of each.


If you go into a computer store and want to buy a new mouse or keyboard, Logitech put the carbon footprint on every product. And so, just as you or I might go into the grocery and assuming two things cost the same, taste the same, we’d likely choose the one that’s healthier. We need to buy the line item and buy the market basket to be able to help choose healthier products. Now, a lot of this is in the manufacturer’s court. In turn, a lot of that is in the FDA’s court, so there’s a lot of regulatory toward really getting a handle on this. We hope the GPOs can be a source of pressure. We hope that organizations providing direct healthcare can be a source of pressure in terms of accelerating this. But the first two buckets, the what we do and the what we burn are fully within our work and we can make great progress there.

Chip Kahn (29:15):

For the purposes of this conversation, John, I’m going to sort of collapse the L and the P, and ask a simple question, which is from the standpoint of the Joint Commission seeing generative AI as the future of understanding what we do and how we perform better than any other vehicle we’ve ever had, what’s your role? What’s the Joint Commission’s role in seeing what I just described happen? Because presumably the technology, I mean, maybe even within the next six months or clearly within the next 12 to 24 months will be there to understand both those things.

Dr. Jonathan Perlin (29:58):

So, let’s take a look at some of the uses of AI now and in the near future, and how it relates to some of the challenges healthcare is experiencing. So, we already have self-driving medical equipment. If you or I have LASIK surgery and AI, small AI, turns off the laser faster than the surgeon can so that the surgeon doesn’t inadvertently slice our eyelet. So, for every blink, the AI is ahead of the human in a totally self running system to prevent damage during the surgery. I see in the near future across environments that there’s one use case that I’m hearing all over. It’s called ambient awareness. It’s using the large language models to synthesize a conversation. So, that one of the things that’s been a bane of clinicians’ existence is pajama documentation, pajama charting. And this is terrible. You have to do your work all day, then you go home and then you have to synthesize what you did.


Imagine a different scenario. Imagine a scenario where the clinician, the patient are together in a room, and an AI is listening. It knows what social conversation, picks up on social conversation, and they have cues, spouse who died, spouse who’s ill, and it tunes in directly to those things that are related to the clinical exam. Ah, a 306 systolic ejection murmur, and it puts it together coherently. This is an immediate use case. It’s an immediate use case that AI might look at how does a nurse stage their work in the day, they go numerically down the hall and then back the other side of the hall? Or do they go to this room first and that room second because the first patient’s being discharged, the second is going to the or the third is MRI appointment, et cetera? And so, whether it’s operations, whether it’s clinical improvement, I’ll come back to that or whether it’s the operation of machine, AI is here.


Now, AI is not one thing. There are little AIs which are use case specific applications like that, LASIK surgery, and there are large language models that’ll allow us to really do assessments in ways that we couldn’t do before. The biggest threat to the improvements in efficiency, safety, and quality for AI is, in my estimation, overzealous, soon well intended, but overzealous overly limiting regulation that says you can’t do this, that or the other. We need to be able to improve healthcare. Did you know that 72% of patients sent to Mayo Clinic for a second opinion have their diagnosis overturned? 30%, overturned so significantly that it requires a different therapy and the first therapy could be dangerous. Another 20%, a significant change in therapy. And the remainder, a change in therapy that may have different clinical outcomes. And just about three weeks ago, Andy Auerbach at the University of California San Francisco published a paper across a number of hospitals that demonstrated that 23% of patients who died or went to ICO with complication, did so because of an incorrect diagnosis.


The amount of data the clinicians have to grapple with is astounding. Just a little thought experiment. When phone numbers first came out, the psychometricians figured that we could manage about seven variables simultaneously. Actually, the range was five to nine. They chose the intermediate. And the number of permutations. Those variables are seven times six, times five, times four, times three, times two, times one. That’s factorial. At least a 5,040 combinations. Let me just show you how complicated healthcare is in contrast. In the average ICU for the average patient, there are about 300 orders in effect and about a 1,000 new data points every hour. That’s 1,300. If I asked you what 1,300 factorial is if I said a million? Nope. A billion? No. A trillion? No. A trillion, trillion? Not even close. I happen to do the calculation, I don’t know this off the top of my head, but it’s 3.16 times 10 to the 3485th power. That’s more than the number of particles estimated in the finite universe. That’s extraordinary. We can’t manage it.


So, it’s not surprising that 72% of patients that Mayo for second opinion have a different diagnosis where the 23% of the time something significant was missed. I want that support through quality and safety standard. We need that support. So, I think it behooves all of us in healthcare to really get involved in self-regulation in a credible way so that we can use the tools that help us save lives, improve quality, improve operations, make care more affordable, and address all of the things that frustrate all of us, not only as clinicians, but as patients in the broader sense, even in the policy context.

Chip Kahn (34:48):

John, to close out, we’ve spent a lot of time on your ambitious agenda and learn so much from what we’ve talked about over the last few minutes. But to close out, let me ask a global question. From your view, having spent 24 months now at the head of the Joint Commission, and knowing that COVID did have an effect on performance and quality, where do you think hospitals are in terms of from the Joint Commission standpoint, your bread and butter, basic role of assuring quality and safety standards are being met? Where are hospitals? And what has to be done to make sure they can get to, I don’t want to call it minimalistic, but at least the basic expectation that when a patient walks through the door, they’re going to get the right care and they’re going to be safe from harm?

Dr. Jonathan Perlin (35:44):

Yeah. First off, I don’t want to miss the opportunity to say thank you to all those clinical colleagues, the administrators who support them who’ve done heroic work. I think it’s fair to say we’re all recovering from the challenge of COVID. And there are so many individuals, so many organizations that have been truly heroic. And I think the word is recovering. We don’t have our foot totally on stable ground in terms of operations as I look across the breadth of hospitals, healthcare organizations in the United States. And to be sure, the Joint Commission’s in 75 countries around the world. And the story is very similar. All are grappling with issues of workforce, all are grappling with issues of finance, all are grappling with issues of special needs populations, behavioral health in particular. Just to put a finer point on it, the Joint Commission has a mandate to inspect to certain conditions of participation that are in law, that are in regulation.


There are some of the things that seem tedious to some of our clinical care colleagues. Some of them were really important. I have a confession. I personally didn’t know what the value of a survey was in terms of inspection. Can you really see things that wouldn’t be visible in a performance measure? And truth is, you can. Paraphrasing or correcting Yogi Berra. You see a lot just by watching. And when I’ve been in hospitals, surveys start to finish. Here’s an issue with infection prevention. I hate to say it. There’s probably a system issue with infection prevention. There’s a life safety issue and fire protections. There’s probably a lack of attention. And so, even though I’m very data-driven. And even though I see the future as being evaluated substantially on data, there is a role and I encourage all of our colleagues, if you haven’t done so, join survey start to finish.


I’d also tell you that our surveyors, because of a public trust accountability, have to hold organizations accountable to what the government demands in terms of a condition for participation in a federal program like Medicare or Medicaid. We’ve been cutting the above and beyond standards, and we’ve been trying to put forward a portfolio that’s really sociably relevant and simultaneously reduces the regulatory burden because we appreciate the fragility of healthcare today. We also want to be in a position where we can help you identify tools to better address some of the areas, whether it’s tapping into those financial incentives for recapitalizing agent, and environmentally damaging, and inefficient infrastructure, or whether it’s flying a flag that you’ve become a beacon of leadership for environmental stewardship so that your young health workers, that your clinicians who are telling us they’re interested in these things, are proud to be a member and support your organization.


Just a quick anecdote, a story of an individual who was the top draft pick for a very name brandy Academic Health System in neurosurgery. Well, there’s this candidate was concluding what was a very positive interview, he asked the department chair, “Tell me about your sustainability program.” And this chair said, “I’m not really sure that we have one.” And his response was, “I’m not sure this is a program for me.” And I realized the plural of anecdote is not data, but the data. Bear this out. That’s a real life example of how committed our younger colleagues are to wanting to be sure that the world that they inherit from us is one that’s more sustainable. And just as we commit to care that’s safer, more effective, more equitable, more accessible, and more compassionate.

Chip Kahn (39:30):

John, thank you for a great conversation and thank you for the role that you’re playing and the advancement of the Joint Commission. At the end of the day, as good a job as all of those who provide care in hospitals can do, you have to have oversight. You have to have quality assurance through somebody frankly looking over your shoulder. And the Joint Commission plays such an important role in doing that and setting the right tone for those providing care and running the hospitals that all of us depend on. So, with that, just so appreciate your time today

Dr. Jonathan Perlin (40:10):

And Chip, let me just thank you and the Federation for your extraordinary leadership and really helping to set the nation’s best possible policy in a world that’s very complex and advocating for healthcare and the missions of all the organizations that we serve. Thank you.

Speaker 1 (40:31):

Thanks for listening to hospitals and focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media @FAHHospitals and follow Chip, @ChipKhan. Please rate review and subscribe to Hospitals In Focus Join us next time for more in-depth conversations with healthcare leaders.


Jonathan B. Perlin

President and Chief Executive Officer, The Joint Commission

Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI became the seventh President and CEO of The Joint Commission Enterprise on March 1, 2022. The Joint Commission Enterprise includes The Joint Commission, Joint Commission Resources (JCR), Joint Commission International (JCI), and the National Quality Forum (NQF).

Previously, as President, Clinical Operations and Chief Medical Officer, HCA Healthcare, Dr. Perlin led clinicians, data scientists and researchers in developing a learning health system model for improving care at the system’s 189 hospitals and 2,200 other locations. His team’s work achieved national recognition for preventing elective pre-term deliveries, reducing maternal mortality, using artificial intelligence to improve sepsis survival, and developing public-private-academic partnerships for improving infection prevention and treating COVID-19. Dr. Perlin’s CHARGE consortium partnered HCA, the Agency for Healthcare Research and Quality (AHRQ) and academia to create a reusable platform for accelerated research using real-world evidence from the care of over 400,000 COVID inpatients.

Before HCA, Dr. Perlin was Under Secretary for Health in the U.S. Department of Veterans Affairs (VA), where he led the Veterans Health Administration (VHA) to national prominence for full implementation of a national electronic health record and benchmark clinical performance. He has served on numerous Federal Commissions including as a Congressional Budget Office Health Advisor, a member of MedPAC (Medicare Payment Advisory Commission), and as chair of the VA Special Medical Advisory Group. An elected member of the National Academy of Medicine (NAM), he has co-chaired NAM action collaboratives on digital health, combatting opioids and climate change.

Dr. Perlin’s board service includes Columbia University’s Health Policy and Management program, Vanderbilt University’s School of Engineering, and he served as a Trustee of Meharry Medical College for 15 years. Perennially recognized as one of the most influential leaders in healthcare, Dr. Perlin maintains faculty appointments at Vanderbilt University as a Clinical Professor of Medicine and at Virginia Commonwealth University as an Adjunct Professor of Health Administration.