The Joint Commission’s Future
In this episode:
- The Joint Commission’s role in working to reduce the health care workforce shortage.
- How TJC is addressing health equity moving forward.
- How hospital measurement is used to assure patients that their hospitals are safe and providing quality care.
Guest: Dr. Jonathan Perlin, M.D., Ph.D., M.S.H.A., M.A.C.P., F.A.C.M.I., President and CEO, The Joint Commission
The Joint Commission is celebrating its 70th anniversary this year; at the helm is Dr. Jon Perlin, previously of HCA Healthcare. Chip talks to Dr. Perlin about his vision for the future of The Joint Commission and the ways the organization can confront issues like social determinants of health and providers impact on climate change.
Speaker 1 (00:05):
Welcome to Hospitals and Focus from the Federation of American Hospitals. Here’s your host, Chip Kahn.
Chip Kahn (00:14):
It has a simple name but a critically important role in assuring quality and safety of patient care, The Joint Commission. Since its inception, The Joint Commission’s mission has been to continuously improve healthcare for the American public by assessing healthcare organizations. As this organization celebrates its 70th anniversary, a new leader is taking the reins with an eye to the future and assuring The Joint Commission becomes even more oriented to healthcare outcomes. Dr. John Perlin is just the seventh president and CEO of The Joint Commission, and he joins us to talk about his priorities and vision for the organization, as well as the direction he sees for healthcare quality evaluation. Welcome, John.
John Perlin (01:04):
Good to see you Chip. It’s a delight to be here with you and many thanks for all that you and the Federation do and have been doing throughout COVID. I know together we’re big fans of all the folks at the front lines and leading healthcare during what probably is the most complex operational political and financial time.
Chip Kahn (01:23):
Well, he really hit the nail on the head, John, and really appreciate it. But let’s get started. You’ve been at the helm of The Joint Commission since March. And before you started, obviously for many years, you were the president of clinical operations and chief medical officer at HCA Healthcare. Can you give us a little bit of background on this transition for you from being at the front lines and now joining, in a sense, one of the key assessors of healthcare organizations in the country, and I really should say internationally also.
John Perlin (01:57):
Well, that’s kind of funny Chip. When they advertised the position description, they said they wanted someone had an academic background, had had government service, understood policy, and had worked in operations. It’s about the closest my resume has ever matched a position description [inaudible 00:02:15]. But it really did, and does, prove to be the perfect background for the work of The Joint Commission. The work in the government’s particularly important in terms of The Joint Commission’s relationship to CMS. CMS is the major sponsor. The Joint Commission of course works as an extension of the regulatory process for CMS in order that hospitals and other healthcare providers can participate in federal programs.
John Perlin (02:41):
The work at MedPAC most recently has been tremendously helpful, being a commissioner, in terms of understanding some of the dimensions of the policy considerations of the Medicare program recently, and by extension, what the implications are for quality and performance for The Joint Commission. Of course, having had the privilege of serving as the CEO of the VA Health System gave me great insight into the operational dimensions, of course, being the president of clinical operations and chief medical officer at HCA, not only gave me additional insights into operations, but particular insight into the operations of the breadth of private sector hospitals right now, and in this brutal culture and of not only COVID, but challenging and divisive healthcare politics and challenging economic environment where the issues of performance are just magnified by the incredible complexity of the current environment.
Chip Kahn (03:43):
John, clearly you just are so well prepared for the new challenge. And I’ve heard you ask the question, why is the world better for having The Joint Commission? I’m now going to throw that back at you since you’re at the helm and ask you what is your answer as the leader now of this organization and seeing the mission through the lens of your vision for it, not someone else’s?
John Perlin (04:10):
So I have to confess Chip. I actually stole that question. I stole it from our mutual friend, Rick Pollack. And I got that question when I had the privilege of being a commissioner to The Joint Commission from the American Hospital Association, roughly 15 years ago. And The Joint Commission is called The Joint Commission because the corporate members, the founding members were American Hospital Association, American Medical Association, the American College of Surgeons, the American Dental Association, and the American College of Physicians. And every year there was a corporate membership meeting at The Joint Commission. And Rick would ask that question, why is the world better? And if you believe that it is, then what can we do to make this an even stronger and better organization? Well, I didn’t really appreciate the answer of that question until COVID. And you and I watched together as 14,000 local municipal health departments across the country tried to grapple with the early requirements for COVID.
John Perlin (05:09):
How did you handle infection prevention? How did you count personal protective equipment? Well, you could either have 14,000 answers or you could have one answer. And The Joint Commission is a highly reliable, highly trained, highly skilled apparatus for assessing performance in order to participate in the federal programs like Medicare and Medicaid. And [inaudible 00:05:33] The Joint Commission, there would be a couple of other ways that either don’t have the depth of skills of the surveyors or have the potential for variation, and all sorts of potential political considerations were done at a state level, but I think its answer is just so straightforward now. The Joint Commission offers a high quality approach to assessing performance and compliance with conditions of participation to participate in federal programs that without which it would be a very painful, very distributed, very idiosyncratic process.
Chip Kahn (06:11):
John, with that in mind, let’s drill down into COVID, because you mentioned COVID. You dealt with COVID on the frontline in your time at HCA Healthcare. How do you see it changing the role of The Joint Commission and the quality evaluation that is basically your mission and purpose?
John Perlin (06:30):
Yes. A great question, Chip. COVID really was a brutally sharp lens that defined the challenges that we have in American healthcare even more greatly. At the very top of my priorities is health equity and a lot of the work that we had done and we’re so proud of in HCA Healthcare that had really reduced things like maternal mortality among women of color, I was challenged by the disparities that exist in the healthcare environment. If not for COVID itself, COVID so disrupted things outside of a hospital’s control, like access to prenatal care and care for continuing conditions that at the very top of my agenda is doing everything we can to use The Joint Commission as a mechanism to support improvements in health equity. The second area is decarbonization. It turns out that healthcare in the United States accounts for about 10% of the US’s entire carbon footprint.
John Perlin (07:30):
And it’s kind of interesting if healthcare were country worldwide, it would be the fourth greatest polluter globally. And it also ties to health equity. The inability to meet the challenges of climate change, as well as the afflictions of diseases that are susceptible to weather extremes like asthma also co-occur with social vulnerabilities. So reducing that carbon footprint is the second priority. And the third is one that I know you were working with your member organizations and that’s on workforce. Right now there is this just perfect storm that pits the needs of patients, of communities, and the healthcare workers themselves at some odds. And we have to find better models of care so that we can meet the needs, first and foremost patients, the communities that hospitals, healthcare organizations are privileged to serve, and the healthcare workers themselves in terms of having a reasonable work life and wellbeing.
John Perlin (08:33):
So as we move forward, think about new models of care. How do we assess those for quality, both in terms of the human models, how the teams come together and in new ways with different skill sets, and how does technology become utilized to not only support care and formal healthcare settings, but distribute care virtually as we’ve certainly witnessed with COVID?
Chip Kahn (08:57):
John, one of the things you’ve mentioned to me recently is as you’ve gotten started, you actually have now been out on full hospital surveys, both domestically in the United States and internationally. What are the insights you can provide our listeners from actually going through with your Joint Commission staff, the work of evaluating hospitals on the front line?
John Perlin (09:24):
So Chip I’m pleased to report that I’ve been a silent observer, both domestically and abroad Joint Commission international operates in 73 countries. So I’ve now done some surveys. And the truth is that I wish I had actually tracked a survey on the receiving end from start to finish. It was really an insightful process. So I have four observations. First, the surveyors are really good. They’re highly skilled individuals. They’re not the surveyors of yore, who are potentially past their prime. These are surveyors who really at top of game and understand healthcare delivery and life safety and contemporary clinical practice. Second, the three words that I used to describe the sense of the survey was that it was of course an accountable process, but it was collaborative and educational. And third, demonstrate that, the two words that I heard the most from surveyors to folks around the hospitals, that I observed surveys that, were show me what you do in the case of fire, for example, or show me how you’d sterilize or show me how you’d maintain sterile process and compounding a medication, the pharmacy, as an example.
John Perlin (10:37):
But fourth, and I think this is the most important thing, I didn’t realize what an extraordinary synthetic view you get of a hospital’s operation, it’s performance. It’s not just infection prevention in the ICU. It’s infection prevention in OR, in sterilization processes, in compounding, in the pharmacy. How do all these things come together? I’ll give you an example. So this is somewhere in a hospital, somewhere in the world where it’s really interesting and it has to do with life safety, fire safety in particular. Imagine a hospital where generally the signage is pretty good, but there’s some problems with signage. Imagine an environment where the egress is pretty good, but not perfect. Imagine an environment where there’s been some drilling, but not consistently.
John Perlin (11:29):
Imagine an environment where there’s some challenges of physical location. Well, everything I’ve described are potentially challenges for hospitals anywhere in the country. But imagine if those all come together with a little bit of a challenge here, a little bit of a challenge there. Here’s the entity that sees it in the aggregate and can raise the flag and say, all of these challenges individually are perhaps not alone significant, but in the aggregate, they’re really risky.
John Perlin (11:59):
How are we going to address that type of risk? And so knowing that the surveyor’s are good, seeing the process being accountable yet collaborative and educational and asking how staff do their work, was really a revealing process. And just to give you an example of the surveyors’ “show me,” at a nursing unit at a hospital with respect to fire safety, I remember the surveyors asking, well, what would you do if there were a fire? And with a lot of turnover, these were newer nurses, clearly committed to mission, clearly caring. They said, we’ll call the emergency number. The question was, okay, what is that number? People kind of looked around the life safety surveyor asked, well, sometimes it’s on your card. Believe me, in that moment, every nurse in the hospital knew that emergency number was on the card. That word gets around. So just a very good process on something that is really synergistic and cannot accrue, even though I’m heavily committed to moving to a more data driven and predictive mechanism for surveying, something that cannot accrue either virtually and without walking a facility, literally subbasement to roof and wing to wing.
Chip Kahn (13:12):
These surveys really have been the main function and the way The Joint Commission has done its job since the early 1950s with its inception. Obviously it had roots earlier in the century, but one of the roles that that fits to is this relationship, which has also been historical with Medicare and Medicaid. With the advent of both programs in the mid sixties, The Joint Commission was a key player in terms of helping the government assure that beneficiaries received good and safe care in hospitals, particularly. Can you talk a bit about what your objectives are for this relationship? How strong do you feel it is, and how do you plan to work to improve it?
John Perlin (14:00):
So this is in a critically important relationship because it’s an interface between all of our colleagues at field at the very front lines of care and the government. And The Joint Commission enjoys the privilege of being in the middle of this relationship because of what’s called deeming authority, and that is meeting Joint Commission accreditation allows a healthcare facility to be deemed, to be in compliance with CMS’s conditions of participation. So let’s take this at two levels. So first and fundamentally, the survey needs to absolutely validate to CMS that a facility is indeed in compliance. There are a set of standards that CMS has. Some of those standards emanate from regulation, that is their executive branch prerogative, and others are in statute, they’re law. And through a good CMS relationship, we’re beginning to create an opportunity to have dialogue about how we move those standards to become more contemporary, more efficient, and ultimately more effective. But obviously regulation and statute take a great deal of effort to make change.
John Perlin (15:12):
A second set of standards come from OSHA. And they’re all about the protection of the healthcare worker themselves. And these standards are really foundational. There are third set of standards that come from The Joint Commission themselves. And I think in contrast to other mechanisms of demonstrating conditions and participation compliance, they really allow a facility to articulate that they are performing at a higher level. There are many more Joint Commission standards than there are federal standards, but having been through the actual survey and seeing how these standards really affect life safety and infection prevention and things that I know from my career as a health services researcher, to be a best practice, it’s an area where it can help shape a quality and safety agenda for a facility and help demonstrate a really exceptional performance in those areas relative to conditions of participation. So my having been in government, by having been on the policy and of advising Congress through MedPAC, it really helps me understand to a greater degree the CMS needs and my having been in operations and government really helps me understand the operational implications.
John Perlin (16:28):
So I think a desire to both support the facility’s effectiveness in all the required dimensions and my ability to understand the requirements, the parameters within which CMS operates, allows us to build a much better and more effective relationship. And I’m absolutely delighted to be working with colleagues like Lee Lecher, chief medical officer, and John Blum in the administrator’s office and the clinical compliance safety and quality team with Michelle Schreiber and other leaders to really help us meet their needs and help facilities perform at the highest level in our common interest, which is the best performing healthcare that we can have.
Chip Kahn (17:12):
Following up on that, John. In terms of acute care hospital, quality and performance measurement, obviously you’ve got the government CMS, you have private payers, you have The Joint Commission, you have other stakeholders who call on healthcare providers and hospitals to provide the results of measurement, but it’s a little bit of a tower of babble sometimes from the standpoint of the provider trying to comply. Should we be moving towards a single platform that everyone uses in terms of quality and performance measurement? What role would you see The Joint Commission playing if it is the right direction to be moving towards some kind of unification of all the expectations of measurement on hospitals, particularly?
John Perlin (18:04):
Yeah, The Joint Commission enjoys a dual role predominantly as the measure evaluator, but in the development of standards, as a measure developer. Standards are effectively measurements. And just getting back to first principles, you and I have had a great deal of discussion on this, is that we need to have a common set of metrics across healthcare that help us demonstrate safety and quality and equity to [inaudible 00:18:29] access and experience and meeting patient need, function, patient reported outcomes. We don’t have that, but Chip, I want to applaud your work, national quality forum with measures application partnership, and really helping to move our country to having a common language for assessing different dimensions of healthcare, performance and value. Obviously we’re not there yet, but I think my disposition, which is to move toward that, and I have a couple of beliefs. First, standards fundamentally are the interrogative of a recommendation and that recommendation has to be based on evidence.
John Perlin (19:05):
And so whether the measures emanate from elsewhere, whether they’re measures that we developed, I think it’s important that we are increasingly transparent in terms of identifying what the basis is for measurement. Second, that we have that common vernacular to be able to compare or cross settings and really learn from best practices on particular measurement. And third, I see the survey of the future being a hybrid, being very data driven based on those measurements and the assessment of outcomes in particular for conditions and parsed by demographics, for example, including race, ethnicity, language, [inaudible 00:19:47], and importantly condition. Also, I think you heard me speak to the value of just hands on eyes on working with healthcare providers. And so that see that survey of future as really being a hybrid between being more intensively data driven, focused on predictive analytics, not just retrospective, and coupled with hands on evaluation and verification, as I think is both inherently important, but as is also required and likely to continue to be required by CMS in terms of conditions of participation.
Chip Kahn (20:25):
Now let’s focus back on one of your key priorities that we’ve sort of covered in the last few comments, the measurement area, it’s this growing shortage in workforce. And it’s frankly, something that of all the challenges probably is the one that keeps operators of hospitals particularly up at night, but it’s really affecting the entire healthcare field. What role can The Joint Commission play here from a safety standpoint and a wellbeing standpoint for staff and also helping hospitals particularly navigate to assure that we have the workforce we need for the patient care that those who come to our hospitals expect?
John Perlin (21:12):
I think there are three dimensions in which The Joint Commission can contribute. One, advocacy, two, improvement, and three, assurance. So let’s start with the advocacy. The Joint Commission has some fundamentally three responsibilities for advocacy. The first is really to a patient, making sure that the patient gets the safest and highest quality care possible. The second, there’s advocacy for the community. And I think this is important because the issue that’s so vexing within a workforce is that some of the proposed remedies would actually offer potential benefit to healthcare workers, but potentially at the detriment to services in a community. Let me come back to that. And of course our advocacy has to be to those healthcare workers themselves. Candidly, I would confess that when some proposed extending triple aim to the quadruple aim and including healthcare worker wellbeing, I felt it was too self-referential, too self-indulgent, but given the challenges of COVID, I think we have to absolutely commit to building a healthier work environment for those who care at the very front lines.
John Perlin (22:25):
And so when you then think about the advocacy for patient community and health worker, it moves you to improvement. And I know we tend to think of Joint Commission on the one hand as central to the compliance requirements for participation in CMS, but Joint Commission has a long and distinguished history of contributing to the health services research, the science of quality and performance. And I mentioned that Joint Commission has not only the international activity, but Joint Commission resources has a mechanism for working with institutions and convening to actually advance the dialogue on topics of particularly importance. And this is of course one. And the insurance is obviously the role of compliance and making sure that the quality is in fact safe and effective. But when you dive into the issues, some would put forward proposals that on the surface seem reasonable, but if you dissect them become problematic.
John Perlin (23:27):
So one of the proposals has been with the attrition. The unprecedented attrition simply have staffing ratios since the issue is worker burnout. Would that really work? Well, there are number of articles that show that for certain conditions, there are better outcomes for some nurse sensitive indicators. On the other hand, in entire states like California, where there have been staffing ratios, and in fact statute that says, hey, you have to preserve a number of other surfaces, I wish we could point to data that say that the outcomes for patients are categorically better. And so there is a big health services research question. How do you actually simultaneously assure a work environment that’s reasonable for caregivers and the best possible staffing for facilities, the absence of which would lead as we’ve observed, and Chip, I’m sure these data better than I do, as we are observing right now, the closure of not only services, but full units on hospitals?
John Perlin (24:34):
And so this is one of the areas where Joint Commission is participating in a work group at IHI to help examine recommendations that can help to reconcile the interests of the community, the interests of the care provider, and fundamentally supporting the quality and safety to patients. There are no easy answers in this, but I believe the answers will be found in two areas. One, new models for care. How do we actually think not about rigid roles, like here’s a staffing ratio, but how do we put together the ideal team and match that team to the needs of a patient? How do we better support nurses with advanced resource nurses? How do we actually bring the medical and the nursing teams together more closely to really guide the therapy? What are other support services that can actually give time back to nurses so they can do the most professional work at the top of their license?
John Perlin (25:35):
How do we reduce burdensome regulatory requirements to how do we make systems more friendly, like electronic health records? In other words, how do we actually bring together certain aspects of technology to create better human resources for care? And I alluded to technology, that’s the other set of solutions? How do we actually allow more junior nurses to get the decision support they need perhaps through expert systems and technologies? How do we use technology to automate processes that now require human labor? How do we use technologies to make sure time’s not lost in finding equipment materials, but rather use technology to make sure that equipment material is in front of the care provider at the time that is needed. So this is a really big vexing question. And I think you and I are going to be facing the implications of this question with our colleagues at the frontline for the next decade.
Chip Kahn (26:33):
John, just in a sense, as you’ve noted, that one size fits all probably won’t work in the workforce area. We have this other area, which was one of your priorities, which is equity, and particularly in the context of what we’ve learned from COVID, this is a real point of emphasis for the administration, for HHS, for CMS and the programs they administer. How does The Joint Commission fit into improving health equity for Americans? So that all Americans that are treated in hospitals and other healthcare organizations can feel like they receive the best care they can possibly get that’s suited to their specific needs?
John Perlin (27:19):
Well, Chip, I think the answer is similar to the three dimensions of the previous question, advocacy improvement, and assurance. In terms of advocacy, it’s something that we are deeply committed to as an extension of mission and vision that all people always receive the best care and the emphasis on all people. In terms of improvement, I think we have a tremendous privilege of being a convening mechanism to bring the best thought together. And in terms of assurance, we can use the tools of both accreditation and higher level certifications to really help align toward advancing healthcare equity. Beginning January 1st in support of both the administration’s interest and our own values, we are introducing six new standards. And some may say these standards don’t go far enough, but we want to make sure that the tide can help to raise all ships. And here they are. The first one is that every accredited entity would designate a leader for health equity, whose role is to focus.
John Perlin (28:20):
It can be someone who has another role, perhaps the chief nursing executive, perhaps the chief medical officer, but someone who’s really leading the clinical healthcare equity. At HCA, we had a chief diversity equity inclusion officer, absolutely fantastic individual, Sherry Neal. She, with our chief nursing executive, Jane Englebright, and I as chief medical officer, who would’ve filled this leadership requirement. Second, there’s an assessment of health related social needs. And obviously the hospital can’t be all things to all people. But so many of the problems that hospitals grapple with, like readmission, are directly related to not meeting certain health related social needs. Simplest, perhaps transportation, back to one’s home environment, as an example. Third, stratifying the quality and safety data. And we learned a tremendous amount by stratifying our data when I had an operational role. And I think that’ll help to not only drive better attention to demographics, but also identifying of disparities that one may not be aware existed and more importantly, working toward remediating.
John Perlin (29:35):
And that leads to fourth, which is creating an action plan. Choose something. Choose one thing and identify an action plan to address reduction of disparity. Fifth, and this is really an extension of the last, is evaluate the effectiveness of the action plan. And sixth, an extension as well, which is to really share that action plan by informing stakeholders, the governance, board, the medical staff, and the staff on the progress on that. So those are six things that will be coming forward as new standards, as part of the accreditation process, starting January 1st. Second, to drive things at a further level, The Joint Commission will be recognizing entities annually through the Bernard Tyson Equity Award, which is truly focused on acknowledging measurable and sustained decreases in healthcare disparity.
John Perlin (30:24):
And so I want to encourage application details on The Joint Commission website and third to get to a higher level. Accreditations are the fundamental requirement for participating as we’ve discussed, but certifications are voluntary and we will be introducing a certification and advanced healthcare equity and more to come on that later in the year, but we’re working on that right now as a way in which interested organizations come align with us with peers and really tackle some of these challenges that get in the way as our vision offers all people always experiencing the highest quality and safest healthcare.
Chip Kahn (31:10):
John, we just so appreciate your service in the academic community, as one of the leaders at VA as a MedPAC commissioner for many, many years at HCA Healthcare. And we really just look forward to your leadership in meeting the challenges at The Joint Commission and really helping both frankly, in the United States and internationally move the quality and performance of healthcare organizations by the role that you’re going to play. So we wish you all the luck and you’ve just been there since March, but I’m sure the place is already shaking.
John Perlin (31:50):
I do bring a different approach, Chip, maybe in closing. It’s really wonderful to have immediate operational experience and bring that to a policy and regulatory environment. And that is changing things. I hope that people will find for the better, because I know we share belief and driving quality, safety, and value, and it’s really in that vein that want to thank you for your exceptional leadership. I know I joined with you in thanking all of our peers across the front lines of healthcare across the leadership suites who’ve been working so very hard in a complex environment, not only on those goals, but on those goals with all of the challenges of the moment. So thanks for the opportunity to be here with you.
Chip Kahn (32:34):
Well, I just appreciate that John, and in our society, particularly change agents make a difference and you’ve always been one. And just as I said, look forward to a long tenure there at The Joint Commission. Thanks a lot.
Speaker 1 (32:52):
Thanks for listening to Hospitals and Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media at FAH Hospitals and follow Chip at Chip Kahn. Please rate, review and subscribe to Hospitals in Focus. Join us next time for more in-depth conversations with healthcare leaders.
Jonathan B. Perlin, M.D., Ph.D., M.S.H.A., M.A.C.P., F.A.C.M.I., became the seventh President and CEO of The Joint Commission on March 1, 2022. Previously, as President, Clinical Operations and Chief Medical Officer, HCA Healthcare, Perlin led clinicians, data scientists and researchers in developing a learning health system model for improving care at the system’s 185 hospitals and 2,200 other locations. His team’s work achieved national recognition for preventing elective pre-term deliveries, reducing maternal mortality, increasing sepsis survival, and developing public-private-academic partnerships for improving infection prevention and treating COVID. Before HCA, Dr. Perlin was Under Secretary for Health in the U.S. Department of Veterans Affairs, where he led the Veterans Health Administration to national prominence for clinical performance. He is a MedPAC Commissioner, a Congressional Budget Office Health Advisor, immediate past chair the National Quality Forum and the VA Special Medical Advisory Group. An elected member of the National Academy of Medicine, he has co-chaired action collaboratives on digital health, combatting opioids and climate change. Board service includes, Meharry Medical College, Columbia University’s Health Policy and Management program, and Vanderbilt University’s School of Engineering. He maintains faculty appointments at Vanderbilt University as Clinical Professor of Medicine and Health Policy and at Virginia Commonwealth University as Adjunct Professor of Health Administration.