August 5, 2025 • 37 mins
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Health Affairs' Rob Lott interviews Jonathan Perlin of The Joint Commission about the origins of this commission, the impacts made on health care through quality improvement and patient safety, the role of accreditation, the public policy levers that drive change, and more.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:00):
Hello, and welcome to A Health I'm your host, Rob
(00:04):
Lott. Friends, it's time foranother very special episode of
A Health Odyssey. As folks know,we typically host the authors of
research papers recentlypublished in the pages of Health
Affairs. But about once a month,we get to look outside that
(00:28):
world and chat with a guest fromthe broader health policy
universe. Today, the veryspecial guest is the
incomparable doctor JonathanPerlin, the president and CEO of
the Joint Commission Enterprise.
For more than seventy years, TheJoint Commission has been the
leading standard setting andaccrediting body in healthcare.
(00:53):
Doctor. Perlin has run theorganization since 2022. Before
that, he served as president forclinical operations and chief
medical officer for HCAHealthcare, which as folks know
is this enormous health system.He was there during COVID and
led the efforts at theirliterally hundreds of locations
(01:15):
focused on preventing andtreating the disease at a huge
scale.
Before HCA, doctor Perlin wasundersecretary for health in the
US Department of VeteransAffairs, where he led the
Veterans Health Administration.Again, not exactly a small
enterprise. Doctor Perlinmaintains faculty appointments
(01:36):
at Vanderbilt University andVirginia Commonwealth
University. Most importantly,he's published a number of
research articles andperspectives in the pages of
health affairs over the years, afriend of the organization. And
so, you know, here in Chicago,we like to cite our great
architects, and it was DanielPernham, of course, who advised
(01:57):
leaders to make no little plans.
So Doctor. Perlin has certainlyhonored that vision during his
career in health and healthcare,and I'm really excited to ask
him all about it. Doctor.Jonathan Perlin, welcome to A
Health Odyssey.
Jonathan Perlin (02:14):
Well, you, Rob, it's a delight to be with you.
Rob Lott (02:17):
So let's just dive right in and maybe very briefly
we can level set for ourlisteners. If you ask most
health affairs readers what theyknow about the Joint Commission,
I think they'd say that it's theaccreditation organization for
hospitals and health systems. Isthat still a fair description of
your core mission?
Jonathan Perlin (02:39):
Well, Rob, that is really a part of the core.
But before we begin in earnest,I want to thank all those
individuals who share our visionthat all people always
experience the safest, highestquality, best value health care
across all settings, becausethat really embraces,
encompasses the accreditationthat is our central role. We
(03:00):
have an administrativeresponsibility. We serve at the
behest of CMS to assure thatcertain structures and processes
are in place to support care.And our mission statement is
enabling and affirming thehighest standards of health care
quality and patient safety forall.
And our responsibility isupholding the public trust that
(03:21):
Care is Safe, that when yourmother or mine go into a
hospital, that they know thatcertain quality structures are
there and that certain safetypractices are in place. But we
go above and beyond what CMSrequires, and we help
organisations address criticalissues like medication safety or
procedural verification, that ifthe right patient getting the
(03:44):
right procedure and that thesurgery is on the right side,
that an organisation is preparedfor emergency operations, and
that we can assure a safeworkplace for patients, staff,
and visitors alike. But we alsohave programs that go across the
continuum of care, and many arevoluntary, But they exist for
(04:07):
hospitals, psychiatrichospitals, ambulatory surgery,
laboratory, medicineenvironments. It's mandatory in
those environments. And on topof accreditation, we offer a
range of certifications thataddress particular programs.
Disease specific certifications,cardiovascular, endocrinology,
orthopedics, or specialtycertifications in other areas
(04:30):
like health equity andsustainable healthcare. Rob, I
think your listeners may beinterested in why Joint
Commission is called JointCommission. And what does that
joint mean? Not that.
Rob Lott (04:43):
You're a bunch of orthopedists,
Jonathan Perlin (04:47):
It is not. It's, you know, Joint Commission
has an extraordinary history.Our predecessor organization was
started by Ernest Codman in1917, in conjunction with the
founding of the American Collegeof Surgeons to assure that the
technical capacity and equipmentfor technical surgery and
technical medicine wasavailable. And that went along
(05:07):
well until World War II. Whatmany may not realise is that
physicians ran hospitals up toWorld War II.
They of course got drafted offto war, and upon coming back the
American College of Surgeonssaid, we can't do this alone. We
need help. And so with theAmerican College of Physicians,
the American MedicalAssociation, the American Dental
(05:30):
Association, the AmericanHospital Association, they
jointly founded the organisationthat we know today as the Joint
Commission. And that actuallygot codified with the Medicare
legislation in 1965 that theJoint Commission would serve as
a non governmental organisationthat extended the capacity of
what's now CMS to be able toassure that certain conditions
(05:53):
were met for participation inthe Medicare, Medicaid and other
federal programs.
Rob Lott (05:57):
Got it, so it's like a team America or sort of an ex
men of all the different healthcare associations tagging tag
teaming the accreditationprocess, is that fair?
Jonathan Perlin (06:11):
It's really five founding organizations that
came together to support themission of assuring that
hospitals and healthcareorganizations had the capacity
for safe care that gotinstantiated into public policy
the founding of Medicare.
Rob Lott (06:29):
Okay, so can you give us a sense of the organization's
scope and reach today? How manyhospitals typically go through
your accreditation process? Ofthose? How many receive the
Joint Commission seal ofapproval? What's that sort of
universe look like today?
Jonathan Perlin (06:49):
Over 80% of US hospitals are accredited through
Joint Commission, and only about1% have an egregious issue that
absolutely interrupts theprocess of moving toward
accreditation. Accreditation,though we enhance beyond what
CMS requires, is really tablestakes for quality and safety.
(07:13):
And we have programs that pushto go beyond through
certification and otherwise. Butin addition to The United
States, what people may notrealize is that we have an
international arm known as JointCommission International, and we
do some work in over 80countries, especially in India,
Indonesia, The Far East, TheMideast, Africa, Latin America.
(07:36):
And the work tends to be inhospitals that are more
sophisticated, lower upperincome country and upper middle
income countries.
But one of the things I'm mostproud of is a very mission
driven program that was launchedthis year. It's called our
Pathways Initiative, and it'sreally meant for capacity
strengthening in lower andmiddle income countries. It's
(07:58):
led by Doctor. Neelam Dhingra,who founded the Patient Safety
Unit at the World HealthOrganization, and the initial
work that we're launching is in15 lower and middle income
countries with particularlyfocused efforts this year in The
Maldives, in The Philippines,and Vietnam. So it's a pretty
broad scope both domesticallyand worldwide.
Rob Lott (08:19):
Yeah, a pretty big reach there. Just going back
briefly, some of some of yourhistory, led the Veterans Health
Administration, obviously apublic sector entity, then many
years with with HCA Healthcare,a for profit enterprise. I'm
curious what it's been likebringing those experiences to
(08:42):
the Joint Commission, which is,not a health system in and of
itself and and and it is a notfor profit organization. How has
that sort of experience been achange for you? I know you've
been there about three years.
And I'm curious how you measureyour own success as the leader
of an organisation like theJoint Commission.
Jonathan Perlin (09:04):
Well, me divide that into two parts, as that I
feel that my professional lifethus far has been a dress
rehearsal for the JointCommission. So I really started
in academia. I didn't intend togo into administration, but I
kept asking why things didn'twork, and found myself more and
more involved in qualityimprovement, and I retread from
(09:25):
molecular neurobiology to healthservices research, ergo the
publications and health affairs,thank you for that opportunity.
But you know the academic rigorand scientific rigor, coupled
with senior governmentalexperience, coupled with large
operational experience across avariety of private settings in
(09:49):
The United States, has reallyimbued me with an understanding
of both the public policy, theuse of evidence for creating
policy, and really the practicalaspects, because like me, our
new senior leadership team,which is just terrific and comes
from senior clinical andoperating roles, kind of gets
(10:13):
this combination of forces thatallows us to both be agile and
more effective. This is atremendously challenging moment
in healthcare in all dimensions,and the folks who are part of
this team really understand howto help organizations succeed
(10:34):
across that variety ofchallenges.
I'll just mention a few names,because I'm really proud of the
team. Doctor. Jim Maralino camefrom the Cleveland Clinic, where
he was Chief Innovation Officer.He's our Chief Innovation
Officer. Doctor.
Liz Mort is our Chief MedicalOfficer. She was the Chief
Quality Officer for Mass GeneralSystem and brings extraordinary
experiences. I mentioned theOlin Dingre, who started the
(10:56):
Patient Safety Unit at the WorldHealth Organization. And Ken
Grubbs actually came from myalma mater at HCA, where he had
responsibility for regulatorycompliance across 2,200 sites of
care. And the entire team isreally oriented toward wanting
to improve the safety andquality of healthcare, but also
(11:20):
do so in a way that reducesburden and improves measurable
performance.
And so that means that I have tomeasure my own success, which I
really measure through ademonstration of value by
improving health care. And Ithink our organisation, the
Joint Commission, has a historyof doing some important things.
(11:43):
We've reduced patient harm andimproved outcomes measurably.
Just last month, I got an emailfrom a friend who's a
journalist. He said, I went infor hand surgery and they signed
my finger.
Was that you guys? Yes, theJoint Commission has a policy
for secure surgical siteverification and that assures
(12:04):
that it's the right procedure onthe right patient in the right
location.
Rob Lott (12:08):
Now building on all that work, the Commission
recently launched, a sort ofrefresh of the accreditation
process. You're calling itAccreditation three sixty colon
the new standard. And the topline message that I've taken
from some of the articles I'veread is that there's a really
dramatic reduction in the numberof requirements running through
(12:32):
that process by about 50% fromthe number I have here is fifth
1,550 requirements or standardsnow coming down to seven seventy
four standards. Obviously, a bigchange there. And I'm wondering,
you maybe start by saying howhow the heck did we reach
(12:53):
fifteen fifty steps in the firstplace, and how are you able to
reduce that number without maybereducing the rigor of the
process along the way?
Jonathan Perlin (13:07):
Yeah, that's a great set of questions, Rob.
This is the biggest revamp ofthe accreditation process, or
the elements that are under ourcontrol, since Medicare was
established in 1965. And let mejust break it into four big
points. First, I want to startagain with a purpose, which is
(13:28):
to uphold public trust in thesafety of healthcare and provide
more effective support forbetter quality. And as I
mentioned, if your family memberor mine goes in for care, we
should expect that the care issafe.
But we desire, on top of theexpectation for safety, the best
(13:51):
possible outcome in managingdisease or improving health. So
that's really the context forthe goal. To the question of why
now? There has never been a morebrutally complex time in health
care, clinically, operationally,financially, even politically.
(14:12):
And so we need to increase ourfocus on what matters most and
reduce the burden to alreadyoverburdened healthcare
organisations and healthcareprofessionals.
And so we felt it was imperativeto simplify the communications
of standards so the expectationsare clear. And so for example,
there was a standard forrecording verbal orders that had
10 separate elements. Those 10elements have been compressed to
(14:37):
one clear statement ofexpectations. To the question
you asked about rigor, it's notless rigorous, it's more
focused. And the example I liketo use is that running a four
minute mile takes way morediscipline than walking for
thirty minutes.
And so we want to focus on whatmatters most. The third point is
(14:59):
really the one that we talkedabout a moment ago, and that is
that we're now led by anoperationally and clinically
experienced leadership team. Thefolks who are in the senior
positions now at the JointCommission, like me, have all
been on the other side ofsurveys. And they kind of
understand what the importantpieces are and what's really
(15:24):
trivial. And we used a filter togo and reassess the standards.
And this is the fourth and finalpoint that we called
accreditation three sixtybecause it's a three sixty
degree look for strengths aswell as concerns. And so in the
(15:45):
reduction of those standards,there were a number of features
that led us to this dramaticreduction. First, we rewrote the
entire standards manual. Weseparated the CMS conditions of
participation from theadditional Joint Commission
requirements. And by the way, webelieve in transparency, so
(16:08):
we're posting all the standardspublicly this month.
Second, we're retiring thosestandards that no longer offer
value. The falters we used, arethey redundant or obsolete? For
example, laws, federalrequirements, etc. Mean that
smoking no longer occurs in UShospitals. Smoking was in three
(16:31):
chapters of the former manual onleadership, environment of care,
and life safety.
And so that meant that we sentlikely at hospitals different
teams about on journeys toaddress something that is now
obsolete. So that's gone.Standards that weren't evidence
(16:53):
based or never cited, they wereeither a bad standard or just
not a problem. Or efforts thatwere disproportionate to the
value of the juice, not worth asqueeze. So those were the
filters that we used to retirestandards that no longer had
value, and I haven't seen awhole lot of tears shed for
these standards that we'veannounced that are gone.
(17:14):
The third is that we've enhancedthe survey report itself. No
longer are we providing feedbackthrough cryptic codes, but
instead we've replaced that withnatural language, particularly
on something we call the SAFRmatrix, which actually plots the
severity of an issue versus theprevalence of an issue. And
(17:35):
rather than having these IC andEC and MS codes on there, we
just have the natural languageof what the issue was. And when
there are a list of issues wherethere might be a citation or
requirement for improvement,they're listed by priority, not
randomly. Fourth, we'veintroduced some, I think, very
(17:55):
useful benchmarking tools.
We've been sitting on fiftyyears of data that we haven't
used, and now an organisationcan look in a particular domain
or compare in a system, onehospital to another, or identify
benchmarks that are similarorganisations. Next, we have
introduced the SAFEST program.This is an acronym for the
(18:18):
survey analysis for evaluatingstrengths, looking for leading
practices, and we're building avideo library of top sighted
performance opportunities. Next,there's an optional continuous
support program. So we don'twant organizations studying for
a test.
You want your doctor, you wantyour nurse, you want your
pharmacist, you want yourhospital to be test ready all
(18:39):
the time. And that's our goal.It's not a gotcha. It's really
meant to give organisations,health workers, the tools to be
as successful as possible. Andfinally, it's really about
surveyor excellence.
The new cadre of surveyors, ofwhich there are over a thousand,
are typically mid careerindividuals, leaders who teach
(19:02):
and enjoy learning, who want totravel and see other approaches.
They appreciate theaccountability aspect to
upholding the public trust, butthey're committed to
improvement. So they go with aneducational imperative and an
intent to be collaborative. Andso in summary, goal is really
(19:23):
better outcomes while reducingburden and better tools and
support for hardworkingcaregivers.
Rob Lott (19:31):
Wow, a lot to process there. I wanna ask you a little
more about how all of thosechanges might translate into,
better care at the end of theday. But first, let's take a
quick break. And we're back. I'mhere with doctor Jonathan
(20:41):
Perlin, president and CEO of theJoint Commission.
We're talking about or werecently heard about the, really
massive changes they'veundertaken to the accreditation
process. And I guess I wanted toask you about, I think there's a
temptation to dismissaccreditation as sort of an
administrative burden, anecessary one at that, but,
(21:05):
burden nonetheless for a lot ofhospitals and health systems.
And I'm wondering, I'm gonnagive you a kind of a softball
here, but I'm gonna ask you toresist the temptation to to
knock it out of the park,instead maybe try to put some
some spin on it and get aninfield hit here. Can you give
me a sort of sunnier version ofthe accreditation story beyond
(21:27):
something that just hospitalsare required to go through and
is instead maybe an experiencethat is integral to their
broader mission?
Jonathan Perlin (21:38):
Well, you know, it's a fair question. And I hope
the work we're doing withAccreditation three sixty helps
to change the survey from beingperceived sometimes as a
regulatory hurdle to really acomponent of a comprehensive
data driven quality improvementprogram. And with that, I want
to get back to first principles.And since you just gave a
baseball metaphor, I want toquote the great philosopher Yogi
(22:01):
Berra, who said famously, Youcan observe a lot just by
watching.
Rob Lott (22:06):
Fair enough.
Jonathan Perlin (22:08):
A confession
some skepticism about surveys. Iwondered if we couldn't actually
do better just with data.Observing a lot just by watching
happened to me in the process ofobserving surveys. And so I want
to tell you a story about what Iobserved at a mid size, say 300
to 400 bed hospital, part as ofa mid size 30 to 70 hospital
(22:33):
system in an average suburb of alarge American city. And so
we're walking around, andbetween two ORs, there's a steam
steriliser autoclave.
And the infection control nurseasks, what's that fair for? So,
well, that's for flashsterilizing instruments. Flash
(22:54):
sterilizing is used when youdon't have something, you need
it immediately. It's not idealbecause the instruments come out
wet and they're not scrubbed inthe same way or packaged in the
same way. So it's a riskierapproach, though decent.
And so the nurses say, must beused pretty infrequently. Oh no,
(23:15):
we use it for every case. Why?Because the doctors like their
particular instruments. How doyou program it?
We use these instructions ontop. There's one of those
plastic folded display frames,and it clearly says instructions
(23:37):
are, for example only, not to beused for programming, and at the
bottom it says downloaded byGoogle, and it was like, oh
gosh, this isn't good. And thenwe walked to the sterile
pharmacy and put on our sterilesuits. On one side everything's
(23:58):
by the book. On the other side,pharmacist or pharmacy tech is
not making the medication that'sgoing to be injected under the
hood, but is changing pipettetips and, you know, sucking up
the solvent outside of the hood.
(24:18):
May as well make it on thekitchen counter. There was a
systematic problem withinfection prevention in this
organization. Now, maybesomething bad hadn't happened
yet. But remember, there wasthis terrible episode in 2012
where a compounding pharmacy inTennessee created these steroids
for epidural injection. Theylikely got away with bad,
(24:42):
inappropriate technique for aperiod of time.
But ultimately, I remember this,there were thirteen thousand
exposures, there were roughlyseven fifty cases, there were
sixty three deaths across 20states. And so the survey helps
uncover latent risk, and latentrisk is a hidden or underlying
condition or a system flaw thathas the potential to cause harm
(25:04):
but hasn't yet resulted inadverse events. And so we have a
big challenge, and that's thatit's incredibly difficult to
measure bad things that don'thappen from uncovering latent
risk. And so the goal isobviously to prevent manifest
harm or actual injury. Butthat's why boots on the ground
(25:24):
and direct observation iscritical.
I believe at this facility weuncover latent risk. And by
helping them change theirpractices prevented actual harm.
It's just difficult to measurethat.
Rob Lott (25:39):
I know we have limited time with you, and I'd like to
touch on a bunch of topicsfairly quickly. So I thought we
could maybe do a little bit of alightning round. We've never
done this on the podcast before,but this seems like a a great
opportunity. I wanna mention anumber of sort of urgent topics
in health care today, and I'dlike you to tell me maybe one
(26:01):
thing, just perhaps a sentenceor two where you're perhaps
feeling optimistic about thattopic, and then we'll go to the
other side and ask you to maybereflect on something that is
leaving you a little, I wasgoing to say worried, but let's
say uncertain about sort of thefuture prospects in this area.
(26:24):
And we'll try to keep it shortand quick for each of these.
Are you game to give this ashot?
Jonathan Perlin (26:30):
Let's play ball. All right. Okay, topic
number one, telehealth.Positive, really not new. Its
use and utility was demonstratedduring COVID.
It's a great way to augmentcare, especially in areas like
behavioural health or supportingmobility impaired or
transportation limited patientsor frail elders. Concern should
(26:53):
provide the same quality as inperson care. And by the way, we
offer a telehealth certificationto assess that.
Rob Lott (27:00):
Great. Yeah, lots of good research in the pages of
Health Affairs as well, a littleplug there into sort of looking
at comparing the quality of caretelehealth versus in person. So
glad that that's on your radaras well. All right, topic number
two, artificial intelligence.
Jonathan Perlin (27:19):
Positive. This is the defining technology of
the century, changes everything.It offers a step change, an
economic term which meansdiscontinuous improvement, in
quality and safety, especiallythings like diagnostic accuracy.
Andy Auerbach at UCSF publisheda paper recently that showed
that twenty three percent ofpatients who die or deteriorate
(27:41):
in American hospitals do sobecause of a missed or a
misdiagnosis. AI has tremendousopportunity to improve that.
Concern? That there areappropriate guardrails to
prevent unintended consequences,harm. For example, chemotherapy
recommendations for childrenthat are based on an adult
population. This is why we arebuilding a responsible use of AI
(28:05):
certification. We want thebenefits, but we want the
appropriate guardrails, and, wewant to facilitate the
innovation, because there's somuch opportunity.
Rob Lott (28:18):
Okay, next topic, vaccines.
Jonathan Perlin (28:21):
Okay, the positive. Things like Project
Warf Speed demonstrated thecapacity of mRNA vaccines in
meeting new epidemic or pandemicthreats. The concerns. Joint
Commission introduced ahealthcare worker flu
vaccination requirement a numberof years ago, and patient deaths
in the newborn intensive careunit and bone marrow transplant
(28:43):
units from identical strains asthe caregivers went down. I
worry about vaccine hesitancy.
Rob Lott (28:51):
Fair enough. Climate change.
Jonathan Perlin (28:54):
Sustainability in health care is critical for
both public health and operatingefficiencies. And in fact,
younger health care workers andclinicians, according to the
Commonwealth Fund, think theyand their organizations should
do more in terms of sustainablehealth care. Healthcare
organizations are 5% ofcommercial force space but
(29:16):
represent 10% of energyconsumption, and hospitals are
three quarters of that 10%. Andso given the cost pressures,
healthcare organisations can'tafford not to hedge their energy
costs. And again, JointCommission offers a sustainable
healthcare certification to helpin organizing that work.
Rob Lott (29:37):
Next one, opioids.
Jonathan Perlin (29:40):
Okay, I'm going to start with a concern first
here. Our country has beenthrough the wringer. But a key
issue is admitted in theconversation. Fundamentally, we
need better pain medications.And the positive here is that AI
and synthetic biology arehelping us find new pathways for
pain medications that arestronger than nonsteroidals but
(30:04):
don't have the addictiveproperties of opiates.
Rob Lott (30:07):
And last but not least, diagnostics.
Jonathan Perlin (30:12):
Oh, well, know, are two pieces here. AI will
improve diagnostic accuracy, asI mentioned. But we're entering
an era where things like theliquid biopsy, essentially a
blood test that says you havecancer, may not say what cancer
could potentially, this is theconcern, generate a number of
false positives that would drivea lot of suffering and
(30:33):
unnecessary and potentialharmful testing and even
procedures.
Rob Lott (30:37):
All right. Well done. Nice work on the lightning
round. I appreciate your playingball here. We're almost out of
time.
I did wanna perhaps wrap up withan opportunity to sort of
reflect. And I know it's beenabout twenty five years since
the landmark paper to is humanwas published reflecting on and
(31:03):
sort of reporting significantgaps in terms of patient safety
and healthcare quality. If wewere to pick a random hospital
patient in a random hospital inAmerica, how do you think their
experience might be differenttoday than it was twenty five
(31:25):
years ago? How might it be thesame? And how is that transition
informing your work at the JointCommission?
Jonathan Perlin (31:34):
Yeah, it's a great question. And I can't
start to address that questionwithout just acknowledging that
we lost one of the pioneers inpatient safety this past month,
Doctor. Lucian Leap, who reallyhelped define that preventable
harm wasn't just a bad outcome,but something that we really
need to think scientificallyabout and take responsibility
(31:57):
for. So let me start with theprogress over the past twenty
five years, then come to whatthat patient might see in a
typical hospital. And I thinkit's important to recognise that
there's been tremendous progressover the last two and a half,
three decades.
First, we have a vocabulary forquality and safety. We have an
(32:19):
understanding of the differencebetween bad outcomes that may
not be preventable andpreventable harm. And consistent
with that, we have a philosophythat preventable harm isn't just
bad luck. There are some papers,there are some who will say,
well, gosh, the rates of errorare unchanged. I'd offer that
that's not entirely accurate.
(32:41):
There's a fair question, whichis why haven't we made more
progress? But let's go back tothis issue that says, well,
things haven't changed. Well,health care has changed. So the
substrate in which failure isbeing measured has changed
immensely. Healthcare is farmore complex and offers far more
in terms of opportunity than itdid three decades ago.
(33:04):
Scientifically, clinically,operationally, financially,
socially, politically,healthcare is tremendously
different than when terroristhuman came out. Let's look at
the clinical opportunities. HIVwas a death sentence. Today,
it's a manageable chronicdisease. Heart failure is no
longer an inevitable consequenceof a major heart attack.
(33:24):
That heart attack can beinterrupted and heart failure
may never occur. And if it doesoccur, are drugs like ACE
inhibitors that can allow heartfailure to be treated, to be
managed. Twenty five years ago,cancers were named by the site
where they were detected. Today,that's far less relevant than
(33:45):
the molecular biology of thecancer, which gives us a key to
unlock doors, not just tomanaging, but oftentimes cure.
And so it's a very differentenvironment.
I think the big challenge thatwe have is that we keep using
the same tools to look forfailure modes. We keep assuming
that if we just record whysomething failed, it'll
(34:06):
generalize to all theircircumstances of failure. And
the classic example is that weremove bottles of potentially
lethal injectable potassium fromlookalike bottles of IV flush
sodium chloride saline. I wisheverything were like that. But
it's not like that.
Nor is health careinterchangeable with aviation.
(34:30):
Aviation is a relatively closedsystem, and it has a set of
identicalities that are verydifferent from healthcare. One
plane of a particular model isidentical to others of the same
model. And if you use thataviation metaphor and take it
even further, the destinationsfor patients aren't necessarily
known beforehand. My flight fromBaltimore to Boston wasn't going
(34:54):
to end up in Burbank or Biloxior Birmingham.
A patient who presents withchest pain could be going to
heart attack or gastritis ordissecting aneurysm or
pneumonia, among any number ofother destinations. There's an
Australian Health Servicesresearcher, Doctor. Braithwaite,
Geoffrey Braithwaite, who's Ithink really helped us by
(35:14):
introducing a concept of Safetytwo point zero, which is really
coupling looking for failuremodes, and Safety two point zero
looking at success modes incomplex adaptive systems, and
trying to understand why thingswork. And this is really part of
why we're introducing our safestprogram, to identify strengths,
(35:35):
to understand how in systemsthat adapt in real time success
can be achieved. And so I thinkthat the opportunity, the real
opportunity, is understandingboth failure modes, that safety
one point zero, and coupling itwith success modes, safety two
point zero, to create safetythree point zero.
So let me come back to what doesthat patient in a hospital
(35:57):
experience? Well, today,compared to twenty five years
ago, they experience electronichealth records that ensure their
past medical history is there,that their allergies are known.
They experience that closed loopof medication administration to
assure that they get the rightdrug and the right dose by the
right route at the right time.They get that nurse and
physician who sign lateral sitesto make sure that the correct
(36:19):
kidney, knee, finger, eyereceive surgery. They get an
organisation that doesn't justreview catastrophe, but an
organisation that has asystematic approach to
understanding close calls.
They get a community that tapsinto safety science, and most
importantly, they get a betterchance for improving health or
(36:40):
curing disease. And that's whatmakes this job so exciting, as
we get to be at the centre ofhelping advance that safety
science.
Rob Lott (36:49):
Wow, a really optimistic view of the last
twenty five years and ofhopefully the years to come. So
Doctor. Perlin, thanks so muchfor taking the time to chat with
us today, I had a great time.
Jonathan Perlin (37:04):
Well Rob, thank you for the privilege of
participating on the Podyssey,and thanks for the important
health reporting you and healthfairs do, and thanks to all who
are advancing healthcare.
Rob Lott (37:13):
For sure, and to our listeners, thanks again for
tuning in. If you enjoyed thisepisode, please tell a friend,
leave a review, and, of course,tune in next week. Thanks,
everyone. Episode, I hope you'lltell a friend about a health
podcast.
Hello, and welcome to A Health I'm your host, Rob
(00:04):
Lott. Friends, it's time foranother very special episode of
A Health Odyssey. As folks know,we typically host the authors of
research papers recentlypublished in the pages of Health
Affairs. But about once a month,we get to look outside that
(00:28):
world and chat with a guest fromthe broader health policy
universe. Today, the veryspecial guest is the
incomparable doctor JonathanPerlin, the president and CEO of
the Joint Commission Enterprise.
For more than seventy years, TheJoint Commission has been the
leading standard setting andaccrediting body in healthcare.
(00:53):
Doctor. Perlin has run theorganization since 2022. Before
that, he served as president forclinical operations and chief
medical officer for HCAHealthcare, which as folks know
is this enormous health system.He was there during COVID and
led the efforts at theirliterally hundreds of locations
(01:15):
focused on preventing andtreating the disease at a huge
scale.
Before HCA, doctor Perlin wasundersecretary for health in the
US Department of VeteransAffairs, where he led the
Veterans Health Administration.Again, not exactly a small
enterprise. Doctor Perlinmaintains faculty appointments
(01:36):
at Vanderbilt University andVirginia Commonwealth
University. Most importantly,he's published a number of
research articles andperspectives in the pages of
health affairs over the years, afriend of the organization. And
so, you know, here in Chicago,we like to cite our great
architects, and it was DanielPernham, of course, who advised
(01:57):
leaders to make no little plans.
So Doctor. Perlin has certainlyhonored that vision during his
career in health and healthcare,and I'm really excited to ask
him all about it. Doctor.Jonathan Perlin, welcome to A
Health Odyssey.
Jonathan Perlin (02:14):
Well, you, Rob, it's a delight to be with you.
Rob Lott (02:17):
So let's just dive right in and maybe very briefly
we can level set for ourlisteners. If you ask most
health affairs readers what theyknow about the Joint Commission,
I think they'd say that it's theaccreditation organization for
hospitals and health systems. Isthat still a fair description of
your core mission?
Jonathan Perlin (02:39):
Well, Rob, that is really a part of the core.
But before we begin in earnest,I want to thank all those
individuals who share our visionthat all people always
experience the safest, highestquality, best value health care
across all settings, becausethat really embraces,
encompasses the accreditationthat is our central role. We
(03:00):
have an administrativeresponsibility. We serve at the
behest of CMS to assure thatcertain structures and processes
are in place to support care.And our mission statement is
enabling and affirming thehighest standards of health care
quality and patient safety forall.
And our responsibility isupholding the public trust that
(03:21):
Care is Safe, that when yourmother or mine go into a
hospital, that they know thatcertain quality structures are
there and that certain safetypractices are in place. But we
go above and beyond what CMSrequires, and we help
organisations address criticalissues like medication safety or
procedural verification, that ifthe right patient getting the
(03:44):
right procedure and that thesurgery is on the right side,
that an organisation is preparedfor emergency operations, and
that we can assure a safeworkplace for patients, staff,
and visitors alike. But we alsohave programs that go across the
continuum of care, and many arevoluntary, But they exist for
(04:07):
hospitals, psychiatrichospitals, ambulatory surgery,
laboratory, medicineenvironments. It's mandatory in
those environments. And on topof accreditation, we offer a
range of certifications thataddress particular programs.
Disease specific certifications,cardiovascular, endocrinology,
orthopedics, or specialtycertifications in other areas
(04:30):
like health equity andsustainable healthcare. Rob, I
think your listeners may beinterested in why Joint
Commission is called JointCommission. And what does that
joint mean? Not that.
Rob Lott (04:43):
You're a bunch of orthopedists,
Jonathan Perlin (04:47):
It is not. It's, you know, Joint Commission
has an extraordinary history.Our predecessor organization was
started by Ernest Codman in1917, in conjunction with the
founding of the American Collegeof Surgeons to assure that the
technical capacity and equipmentfor technical surgery and
technical medicine wasavailable. And that went along
(05:07):
well until World War II. Whatmany may not realise is that
physicians ran hospitals up toWorld War II.
They of course got drafted offto war, and upon coming back the
American College of Surgeonssaid, we can't do this alone. We
need help. And so with theAmerican College of Physicians,
the American MedicalAssociation, the American Dental
(05:30):
Association, the AmericanHospital Association, they
jointly founded the organisationthat we know today as the Joint
Commission. And that actuallygot codified with the Medicare
legislation in 1965 that theJoint Commission would serve as
a non governmental organisationthat extended the capacity of
what's now CMS to be able toassure that certain conditions
(05:53):
were met for participation inthe Medicare, Medicaid and other
federal programs.
Rob Lott (05:57):
Got it, so it's like a team America or sort of an ex
men of all the different healthcare associations tagging tag
teaming the accreditationprocess, is that fair?
Jonathan Perlin (06:11):
It's really five founding organizations that
came together to support themission of assuring that
hospitals and healthcareorganizations had the capacity
for safe care that gotinstantiated into public policy
the founding of Medicare.
Rob Lott (06:29):
Okay, so can you give us a sense of the organization's
scope and reach today? How manyhospitals typically go through
your accreditation process? Ofthose? How many receive the
Joint Commission seal ofapproval? What's that sort of
universe look like today?
Jonathan Perlin (06:49):
Over 80% of US hospitals are accredited through
Joint Commission, and only about1% have an egregious issue that
absolutely interrupts theprocess of moving toward
accreditation. Accreditation,though we enhance beyond what
CMS requires, is really tablestakes for quality and safety.
(07:13):
And we have programs that pushto go beyond through
certification and otherwise. Butin addition to The United
States, what people may notrealize is that we have an
international arm known as JointCommission International, and we
do some work in over 80countries, especially in India,
Indonesia, The Far East, TheMideast, Africa, Latin America.
(07:36):
And the work tends to be inhospitals that are more
sophisticated, lower upperincome country and upper middle
income countries.
But one of the things I'm mostproud of is a very mission
driven program that was launchedthis year. It's called our
Pathways Initiative, and it'sreally meant for capacity
strengthening in lower andmiddle income countries. It's
(07:58):
led by Doctor. Neelam Dhingra,who founded the Patient Safety
Unit at the World HealthOrganization, and the initial
work that we're launching is in15 lower and middle income
countries with particularlyfocused efforts this year in The
Maldives, in The Philippines,and Vietnam. So it's a pretty
broad scope both domesticallyand worldwide.
Rob Lott (08:19):
Yeah, a pretty big reach there. Just going back
briefly, some of some of yourhistory, led the Veterans Health
Administration, obviously apublic sector entity, then many
years with with HCA Healthcare,a for profit enterprise. I'm
curious what it's been likebringing those experiences to
(08:42):
the Joint Commission, which is,not a health system in and of
itself and and and it is a notfor profit organization. How has
that sort of experience been achange for you? I know you've
been there about three years.
And I'm curious how you measureyour own success as the leader
of an organisation like theJoint Commission.
Jonathan Perlin (09:04):
Well, me divide that into two parts, as that I
feel that my professional lifethus far has been a dress
rehearsal for the JointCommission. So I really started
in academia. I didn't intend togo into administration, but I
kept asking why things didn'twork, and found myself more and
more involved in qualityimprovement, and I retread from
(09:25):
molecular neurobiology to healthservices research, ergo the
publications and health affairs,thank you for that opportunity.
But you know the academic rigorand scientific rigor, coupled
with senior governmentalexperience, coupled with large
operational experience across avariety of private settings in
(09:49):
The United States, has reallyimbued me with an understanding
of both the public policy, theuse of evidence for creating
policy, and really the practicalaspects, because like me, our
new senior leadership team,which is just terrific and comes
from senior clinical andoperating roles, kind of gets
(10:13):
this combination of forces thatallows us to both be agile and
more effective. This is atremendously challenging moment
in healthcare in all dimensions,and the folks who are part of
this team really understand howto help organizations succeed
(10:34):
across that variety ofchallenges.
I'll just mention a few names,because I'm really proud of the
team. Doctor. Jim Maralino camefrom the Cleveland Clinic, where
he was Chief Innovation Officer.He's our Chief Innovation
Officer. Doctor.
Liz Mort is our Chief MedicalOfficer. She was the Chief
Quality Officer for Mass GeneralSystem and brings extraordinary
experiences. I mentioned theOlin Dingre, who started the
(10:56):
Patient Safety Unit at the WorldHealth Organization. And Ken
Grubbs actually came from myalma mater at HCA, where he had
responsibility for regulatorycompliance across 2,200 sites of
care. And the entire team isreally oriented toward wanting
to improve the safety andquality of healthcare, but also
(11:20):
do so in a way that reducesburden and improves measurable
performance.
And so that means that I have tomeasure my own success, which I
really measure through ademonstration of value by
improving health care. And Ithink our organisation, the
Joint Commission, has a historyof doing some important things.
(11:43):
We've reduced patient harm andimproved outcomes measurably.
Just last month, I got an emailfrom a friend who's a
journalist. He said, I went infor hand surgery and they signed
my finger.
Was that you guys? Yes, theJoint Commission has a policy
for secure surgical siteverification and that assures
(12:04):
that it's the right procedure onthe right patient in the right
location.
Rob Lott (12:08):
Now building on all that work, the Commission
recently launched, a sort ofrefresh of the accreditation
process. You're calling itAccreditation three sixty colon
the new standard. And the topline message that I've taken
from some of the articles I'veread is that there's a really
dramatic reduction in the numberof requirements running through
(12:32):
that process by about 50% fromthe number I have here is fifth
1,550 requirements or standardsnow coming down to seven seventy
four standards. Obviously, a bigchange there. And I'm wondering,
you maybe start by saying howhow the heck did we reach
(12:53):
fifteen fifty steps in the firstplace, and how are you able to
reduce that number without maybereducing the rigor of the
process along the way?
Jonathan Perlin (13:07):
Yeah, that's a great set of questions, Rob.
This is the biggest revamp ofthe accreditation process, or
the elements that are under ourcontrol, since Medicare was
established in 1965. And let mejust break it into four big
points. First, I want to startagain with a purpose, which is
(13:28):
to uphold public trust in thesafety of healthcare and provide
more effective support forbetter quality. And as I
mentioned, if your family memberor mine goes in for care, we
should expect that the care issafe.
But we desire, on top of theexpectation for safety, the best
(13:51):
possible outcome in managingdisease or improving health. So
that's really the context forthe goal. To the question of why
now? There has never been a morebrutally complex time in health
care, clinically, operationally,financially, even politically.
(14:12):
And so we need to increase ourfocus on what matters most and
reduce the burden to alreadyoverburdened healthcare
organisations and healthcareprofessionals.
And so we felt it was imperativeto simplify the communications
of standards so the expectationsare clear. And so for example,
there was a standard forrecording verbal orders that had
10 separate elements. Those 10elements have been compressed to
(14:37):
one clear statement ofexpectations. To the question
you asked about rigor, it's notless rigorous, it's more
focused. And the example I liketo use is that running a four
minute mile takes way morediscipline than walking for
thirty minutes.
And so we want to focus on whatmatters most. The third point is
(14:59):
really the one that we talkedabout a moment ago, and that is
that we're now led by anoperationally and clinically
experienced leadership team. Thefolks who are in the senior
positions now at the JointCommission, like me, have all
been on the other side ofsurveys. And they kind of
understand what the importantpieces are and what's really
(15:24):
trivial. And we used a filter togo and reassess the standards.
And this is the fourth and finalpoint that we called
accreditation three sixtybecause it's a three sixty
degree look for strengths aswell as concerns. And so in the
(15:45):
reduction of those standards,there were a number of features
that led us to this dramaticreduction. First, we rewrote the
entire standards manual. Weseparated the CMS conditions of
participation from theadditional Joint Commission
requirements. And by the way, webelieve in transparency, so
(16:08):
we're posting all the standardspublicly this month.
Second, we're retiring thosestandards that no longer offer
value. The falters we used, arethey redundant or obsolete? For
example, laws, federalrequirements, etc. Mean that
smoking no longer occurs in UShospitals. Smoking was in three
(16:31):
chapters of the former manual onleadership, environment of care,
and life safety.
And so that meant that we sentlikely at hospitals different
teams about on journeys toaddress something that is now
obsolete. So that's gone.Standards that weren't evidence
(16:53):
based or never cited, they wereeither a bad standard or just
not a problem. Or efforts thatwere disproportionate to the
value of the juice, not worth asqueeze. So those were the
filters that we used to retirestandards that no longer had
value, and I haven't seen awhole lot of tears shed for
these standards that we'veannounced that are gone.
(17:14):
The third is that we've enhancedthe survey report itself. No
longer are we providing feedbackthrough cryptic codes, but
instead we've replaced that withnatural language, particularly
on something we call the SAFRmatrix, which actually plots the
severity of an issue versus theprevalence of an issue. And
(17:35):
rather than having these IC andEC and MS codes on there, we
just have the natural languageof what the issue was. And when
there are a list of issues wherethere might be a citation or
requirement for improvement,they're listed by priority, not
randomly. Fourth, we'veintroduced some, I think, very
(17:55):
useful benchmarking tools.
We've been sitting on fiftyyears of data that we haven't
used, and now an organisationcan look in a particular domain
or compare in a system, onehospital to another, or identify
benchmarks that are similarorganisations. Next, we have
introduced the SAFEST program.This is an acronym for the
(18:18):
survey analysis for evaluatingstrengths, looking for leading
practices, and we're building avideo library of top sighted
performance opportunities. Next,there's an optional continuous
support program. So we don'twant organizations studying for
a test.
You want your doctor, you wantyour nurse, you want your
pharmacist, you want yourhospital to be test ready all
(18:39):
the time. And that's our goal.It's not a gotcha. It's really
meant to give organisations,health workers, the tools to be
as successful as possible. Andfinally, it's really about
surveyor excellence.
The new cadre of surveyors, ofwhich there are over a thousand,
are typically mid careerindividuals, leaders who teach
(19:02):
and enjoy learning, who want totravel and see other approaches.
They appreciate theaccountability aspect to
upholding the public trust, butthey're committed to
improvement. So they go with aneducational imperative and an
intent to be collaborative. Andso in summary, goal is really
(19:23):
better outcomes while reducingburden and better tools and
support for hardworkingcaregivers.
Rob Lott (19:31):
Wow, a lot to process there. I wanna ask you a little
more about how all of thosechanges might translate into,
better care at the end of theday. But first, let's take a
quick break. And we're back. I'mhere with doctor Jonathan
(20:41):
Perlin, president and CEO of theJoint Commission.
We're talking about or werecently heard about the, really
massive changes they'veundertaken to the accreditation
process. And I guess I wanted toask you about, I think there's a
temptation to dismissaccreditation as sort of an
administrative burden, anecessary one at that, but,
(21:05):
burden nonetheless for a lot ofhospitals and health systems.
And I'm wondering, I'm gonnagive you a kind of a softball
here, but I'm gonna ask you toresist the temptation to to
knock it out of the park,instead maybe try to put some
some spin on it and get aninfield hit here. Can you give
me a sort of sunnier version ofthe accreditation story beyond
(21:27):
something that just hospitalsare required to go through and
is instead maybe an experiencethat is integral to their
broader mission?
Jonathan Perlin (21:38):
Well, you know, it's a fair question. And I hope
the work we're doing withAccreditation three sixty helps
to change the survey from beingperceived sometimes as a
regulatory hurdle to really acomponent of a comprehensive
data driven quality improvementprogram. And with that, I want
to get back to first principles.And since you just gave a
baseball metaphor, I want toquote the great philosopher Yogi
(22:01):
Berra, who said famously, Youcan observe a lot just by
watching.
Rob Lott (22:06):
Fair enough.
Jonathan Perlin (22:08):
A confession
some skepticism about surveys. Iwondered if we couldn't actually
do better just with data.Observing a lot just by watching
happened to me in the process ofobserving surveys. And so I want
to tell you a story about what Iobserved at a mid size, say 300
to 400 bed hospital, part as ofa mid size 30 to 70 hospital
(22:33):
system in an average suburb of alarge American city. And so
we're walking around, andbetween two ORs, there's a steam
steriliser autoclave.
And the infection control nurseasks, what's that fair for? So,
well, that's for flashsterilizing instruments. Flash
(22:54):
sterilizing is used when youdon't have something, you need
it immediately. It's not idealbecause the instruments come out
wet and they're not scrubbed inthe same way or packaged in the
same way. So it's a riskierapproach, though decent.
And so the nurses say, must beused pretty infrequently. Oh no,
(23:15):
we use it for every case. Why?Because the doctors like their
particular instruments. How doyou program it?
We use these instructions ontop. There's one of those
plastic folded display frames,and it clearly says instructions
(23:37):
are, for example only, not to beused for programming, and at the
bottom it says downloaded byGoogle, and it was like, oh
gosh, this isn't good. And thenwe walked to the sterile
pharmacy and put on our sterilesuits. On one side everything's
(23:58):
by the book. On the other side,pharmacist or pharmacy tech is
not making the medication that'sgoing to be injected under the
hood, but is changing pipettetips and, you know, sucking up
the solvent outside of the hood.
(24:18):
May as well make it on thekitchen counter. There was a
systematic problem withinfection prevention in this
organization. Now, maybesomething bad hadn't happened
yet. But remember, there wasthis terrible episode in 2012
where a compounding pharmacy inTennessee created these steroids
for epidural injection. Theylikely got away with bad,
(24:42):
inappropriate technique for aperiod of time.
But ultimately, I remember this,there were thirteen thousand
exposures, there were roughlyseven fifty cases, there were
sixty three deaths across 20states. And so the survey helps
uncover latent risk, and latentrisk is a hidden or underlying
condition or a system flaw thathas the potential to cause harm
(25:04):
but hasn't yet resulted inadverse events. And so we have a
big challenge, and that's thatit's incredibly difficult to
measure bad things that don'thappen from uncovering latent
risk. And so the goal isobviously to prevent manifest
harm or actual injury. Butthat's why boots on the ground
(25:24):
and direct observation iscritical.
I believe at this facility weuncover latent risk. And by
helping them change theirpractices prevented actual harm.
It's just difficult to measurethat.
Rob Lott (25:39):
I know we have limited time with you, and I'd like to
touch on a bunch of topicsfairly quickly. So I thought we
could maybe do a little bit of alightning round. We've never
done this on the podcast before,but this seems like a a great
opportunity. I wanna mention anumber of sort of urgent topics
in health care today, and I'dlike you to tell me maybe one
(26:01):
thing, just perhaps a sentenceor two where you're perhaps
feeling optimistic about thattopic, and then we'll go to the
other side and ask you to maybereflect on something that is
leaving you a little, I wasgoing to say worried, but let's
say uncertain about sort of thefuture prospects in this area.
(26:24):
And we'll try to keep it shortand quick for each of these.
Are you game to give this ashot?
Jonathan Perlin (26:30):
Let's play ball. All right. Okay, topic
number one, telehealth.Positive, really not new. Its
use and utility was demonstratedduring COVID.
It's a great way to augmentcare, especially in areas like
behavioural health or supportingmobility impaired or
transportation limited patientsor frail elders. Concern should
(26:53):
provide the same quality as inperson care. And by the way, we
offer a telehealth certificationto assess that.
Rob Lott (27:00):
Great. Yeah, lots of good research in the pages of
Health Affairs as well, a littleplug there into sort of looking
at comparing the quality of caretelehealth versus in person. So
glad that that's on your radaras well. All right, topic number
two, artificial intelligence.
Jonathan Perlin (27:19):
Positive. This is the defining technology of
the century, changes everything.It offers a step change, an
economic term which meansdiscontinuous improvement, in
quality and safety, especiallythings like diagnostic accuracy.
Andy Auerbach at UCSF publisheda paper recently that showed
that twenty three percent ofpatients who die or deteriorate
(27:41):
in American hospitals do sobecause of a missed or a
misdiagnosis. AI has tremendousopportunity to improve that.
Concern? That there areappropriate guardrails to
prevent unintended consequences,harm. For example, chemotherapy
recommendations for childrenthat are based on an adult
population. This is why we arebuilding a responsible use of AI
(28:05):
certification. We want thebenefits, but we want the
appropriate guardrails, and, wewant to facilitate the
innovation, because there's somuch opportunity.
Rob Lott (28:18):
Okay, next topic, vaccines.
Jonathan Perlin (28:21):
Okay, the positive. Things like Project
Warf Speed demonstrated thecapacity of mRNA vaccines in
meeting new epidemic or pandemicthreats. The concerns. Joint
Commission introduced ahealthcare worker flu
vaccination requirement a numberof years ago, and patient deaths
in the newborn intensive careunit and bone marrow transplant
(28:43):
units from identical strains asthe caregivers went down. I
worry about vaccine hesitancy.
Rob Lott (28:51):
Fair enough. Climate change.
Jonathan Perlin (28:54):
Sustainability in health care is critical for
both public health and operatingefficiencies. And in fact,
younger health care workers andclinicians, according to the
Commonwealth Fund, think theyand their organizations should
do more in terms of sustainablehealth care. Healthcare
organizations are 5% ofcommercial force space but
(29:16):
represent 10% of energyconsumption, and hospitals are
three quarters of that 10%. Andso given the cost pressures,
healthcare organisations can'tafford not to hedge their energy
costs. And again, JointCommission offers a sustainable
healthcare certification to helpin organizing that work.
Rob Lott (29:37):
Next one, opioids.
Jonathan Perlin (29:40):
Okay, I'm going to start with a concern first
here. Our country has beenthrough the wringer. But a key
issue is admitted in theconversation. Fundamentally, we
need better pain medications.And the positive here is that AI
and synthetic biology arehelping us find new pathways for
pain medications that arestronger than nonsteroidals but
(30:04):
don't have the addictiveproperties of opiates.
Rob Lott (30:07):
And last but not least, diagnostics.
Jonathan Perlin (30:12):
Oh, well, know, are two pieces here. AI will
improve diagnostic accuracy, asI mentioned. But we're entering
an era where things like theliquid biopsy, essentially a
blood test that says you havecancer, may not say what cancer
could potentially, this is theconcern, generate a number of
false positives that would drivea lot of suffering and
(30:33):
unnecessary and potentialharmful testing and even
procedures.
Rob Lott (30:37):
All right. Well done. Nice work on the lightning
round. I appreciate your playingball here. We're almost out of
time.
I did wanna perhaps wrap up withan opportunity to sort of
reflect. And I know it's beenabout twenty five years since
the landmark paper to is humanwas published reflecting on and
(31:03):
sort of reporting significantgaps in terms of patient safety
and healthcare quality. If wewere to pick a random hospital
patient in a random hospital inAmerica, how do you think their
experience might be differenttoday than it was twenty five
(31:25):
years ago? How might it be thesame? And how is that transition
informing your work at the JointCommission?
Jonathan Perlin (31:34):
Yeah, it's a great question. And I can't
start to address that questionwithout just acknowledging that
we lost one of the pioneers inpatient safety this past month,
Doctor. Lucian Leap, who reallyhelped define that preventable
harm wasn't just a bad outcome,but something that we really
need to think scientificallyabout and take responsibility
(31:57):
for. So let me start with theprogress over the past twenty
five years, then come to whatthat patient might see in a
typical hospital. And I thinkit's important to recognise that
there's been tremendous progressover the last two and a half,
three decades.
First, we have a vocabulary forquality and safety. We have an
(32:19):
understanding of the differencebetween bad outcomes that may
not be preventable andpreventable harm. And consistent
with that, we have a philosophythat preventable harm isn't just
bad luck. There are some papers,there are some who will say,
well, gosh, the rates of errorare unchanged. I'd offer that
that's not entirely accurate.
(32:41):
There's a fair question, whichis why haven't we made more
progress? But let's go back tothis issue that says, well,
things haven't changed. Well,health care has changed. So the
substrate in which failure isbeing measured has changed
immensely. Healthcare is farmore complex and offers far more
in terms of opportunity than itdid three decades ago.
(33:04):
Scientifically, clinically,operationally, financially,
socially, politically,healthcare is tremendously
different than when terroristhuman came out. Let's look at
the clinical opportunities. HIVwas a death sentence. Today,
it's a manageable chronicdisease. Heart failure is no
longer an inevitable consequenceof a major heart attack.
(33:24):
That heart attack can beinterrupted and heart failure
may never occur. And if it doesoccur, are drugs like ACE
inhibitors that can allow heartfailure to be treated, to be
managed. Twenty five years ago,cancers were named by the site
where they were detected. Today,that's far less relevant than
(33:45):
the molecular biology of thecancer, which gives us a key to
unlock doors, not just tomanaging, but oftentimes cure.
And so it's a very differentenvironment.
I think the big challenge thatwe have is that we keep using
the same tools to look forfailure modes. We keep assuming
that if we just record whysomething failed, it'll
(34:06):
generalize to all theircircumstances of failure. And
the classic example is that weremove bottles of potentially
lethal injectable potassium fromlookalike bottles of IV flush
sodium chloride saline. I wisheverything were like that. But
it's not like that.
Nor is health careinterchangeable with aviation.
(34:30):
Aviation is a relatively closedsystem, and it has a set of
identicalities that are verydifferent from healthcare. One
plane of a particular model isidentical to others of the same
model. And if you use thataviation metaphor and take it
even further, the destinationsfor patients aren't necessarily
known beforehand. My flight fromBaltimore to Boston wasn't going
(34:54):
to end up in Burbank or Biloxior Birmingham.
A patient who presents withchest pain could be going to
heart attack or gastritis ordissecting aneurysm or
pneumonia, among any number ofother destinations. There's an
Australian Health Servicesresearcher, Doctor. Braithwaite,
Geoffrey Braithwaite, who's Ithink really helped us by
(35:14):
introducing a concept of Safetytwo point zero, which is really
coupling looking for failuremodes, and Safety two point zero
looking at success modes incomplex adaptive systems, and
trying to understand why thingswork. And this is really part of
why we're introducing our safestprogram, to identify strengths,
(35:35):
to understand how in systemsthat adapt in real time success
can be achieved. And so I thinkthat the opportunity, the real
opportunity, is understandingboth failure modes, that safety
one point zero, and coupling itwith success modes, safety two
point zero, to create safetythree point zero.
So let me come back to what doesthat patient in a hospital
(35:57):
experience? Well, today,compared to twenty five years
ago, they experience electronichealth records that ensure their
past medical history is there,that their allergies are known.
They experience that closed loopof medication administration to
assure that they get the rightdrug and the right dose by the
right route at the right time.They get that nurse and
physician who sign lateral sitesto make sure that the correct
(36:19):
kidney, knee, finger, eyereceive surgery. They get an
organisation that doesn't justreview catastrophe, but an
organisation that has asystematic approach to
understanding close calls.
They get a community that tapsinto safety science, and most
importantly, they get a betterchance for improving health or
(36:40):
curing disease. And that's whatmakes this job so exciting, as
we get to be at the centre ofhelping advance that safety
science.
Rob Lott (36:49):
Wow, a really optimistic view of the last
twenty five years and ofhopefully the years to come. So
Doctor. Perlin, thanks so muchfor taking the time to chat with
us today, I had a great time.
Jonathan Perlin (37:04):
Well Rob, thank you for the privilege of
participating on the Podyssey,and thanks for the important
health reporting you and healthfairs do, and thanks to all who
are advancing healthcare.
Rob Lott (37:13):
For sure, and to our listeners, thanks again for
tuning in. If you enjoyed thisepisode, please tell a friend,
leave a review, and, of course,tune in next week. Thanks,
everyone. Episode, I hope you'lltell a friend about a health
podcast.
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