Health Equity, Environmental Sustainability, Workforce: The Joint Commissions Three Strategic Priorities
Thomas H. Lee, MD, MS was interviewed by Jonathan B. Perlini, MD, PhD, MSHA, MACP, FACMI, Joint Commission Chairman and CEO.
Tom Lee:
I'm Tom Lee, editor-in-chief of NEJM Catalyst, and today we spoke with Dr. John Perlin, who became chairman and CEO of The Joint Commission in March 2022. Throughout his career, John has been a force for improving health care. and he is not afraid to do this work on a large scale.
We first met when he was Under Secretary of Health at the US Department of Veterans Affairs (VA) in the 1990s, and he worked with Ken Kizer to make the VA a national leader in several aspects of quality. Most recently, he was HCA Healthcare's chief medical officer and led quality improvement at the system's 185 hospitals and 2,200 other facilities.
In all of these roles, he has earned the respect of his health care colleagues, and we are all excited to see where the Joint Commission will go during his tenure. John, could you start today with a brief explanation of the Joint Commission?
John Perlin.
Tom, good to be here with you. Thank you for having me. Today's Joint Commission is three things: (1) inspiration, (2) improvement, and (3) accountability. Let's break them down in this order.
I don't know if everyone knows why the Joint Commission is called the Joint Commission, but it has to do with the inspiration that comes from health care and the practice of medicine itself. The organization, which preceded the Joint Commission, followed in the footsteps of Ernest Codman Flexner's report on quality evidence-based medicine and was founded by the American College of Surgeons to ensure that hospitals were able to provide the best possible care. 1 - 3:
The American College of Surgeons continued to review this hospital during World War II, but as you would expect, the doctors were recruited during World War II. After World War II, there was a need for management professionals and the American College of Surgeons to share this responsibility with others.
The American College of Surgeons, along with the American Medical Association, the American College of Physicians, the American Dental Association, and the American Hospital Association, formed this new organization, The Joint Commission. The goal is to inspire and improve.
Today's Joint Improvement Committee is about three organizations. There is the Joint Commission, which we are all familiar with in terms of investigations into hospitals and other medical facilities. There is also the Joint Commission Resources (JCR), which provides training and advisory tools that increasingly focus not only on accreditation but also on all forms of improvement. One of the most interesting is that the Joint Commission operates internationally in the 76 countries it accredits, supporting improvements there.
The third element, in addition to inspiration and sophistication, is related to responsibility. The Joint Commission's standards come from a variety of places. Some of the improvements and inspiration came from us [the Joint Commission] -- [later] when we pared it down and there were standards that came from the Centers for Medicare and Medicaid Services (CMS) and OSHA (the Occupational Safety and Health Administration ).
To be eligible for a federal program like Medicare, you must be in good standing with them. There are organizations that can assess compliance, and if an organization passes this assessment, it is considered compliant. He is responsible for reviewing regulatory requirements for participation in federal programs.
On a practical level, Tom, I have had a hands-on approach since March 1, 2022. I have participated in both surveys from start to finish. The surveyors of today are not the surveyors of the past. These are usually active professionals at the peak of their careers. They are very knowledgeable. What I appreciate most is that they have a balanced education and responsibility.
The phrase I hear the most is "Tell me." “Tell me how you will fight the fire. Show how you maintain sterile equipment. To be honest, I would like to be on the survey from start to finish because you can see how the different criteria, elements and performance come together. Some elements may seem demanding, even trivial, but overall, for areas such as infection or fire prevention, these small touch points can be very important. This is a very integrative and synthetic vision.
Finally, let me say that as you said, I just came from HCA Health. By the time I left, we had treated more than 400,000 hospitalized patients positive for Covid-19. I look at our role from an operational point of view, and from the point of view of the sensitivity of this health care, we are looking for ways to reduce the burden on health workers and health organizations that are particularly facing the complexities caused by Covid-19. at this moment.
Li:
Despitethese ambitious goals, we both know that the [healthcare organizations] being evaluated tend to believe that the Joint Commission is conducting life-or-death trials, even though we know that the Joint Commission promotes health care. to the goal without harm and become the learning organization you describe.
In the next step, you talk about the way forward. You have identified three new key strategic priorities. Let's take a look at them and what they mean for health care and the organizations that work with the Joint Commission.
Pearly.
A lot. We'll come back to clear the deck and focus on some of these, but the point is that they are directional rather than prescriptive. The focus is on three things that are absolutely essential to improving health care. These are (1) health equity, (2) environmental sustainability, and (3) the workforce, both in terms of new treatment models and the sustainability of the workforce itself. I have accelerated our focus on each of these priority areas, and I am pleased to report that we have made progress.
Li:
Let's get started and discuss what you're focused on and what you think the Joint Commission can do to move health care in the right direction. Let's start with health equity. We've all learned a lot in recent years, but what do you think organizations need to do to achieve this goal?
Pearly.
The last few years, especially during Covid-19 and all the violent disruptions, have shown what was always unacceptable [and] has become unbearable. As an organization, we operate on the belief that justice must be at the heart of everything we do in healthcare. Without justice, there cannot and will not even be the possibility of safe treatment.
We believe that reducing health disparities is not only a quality and safety requirement, but also our moral and ethical responsibility. In the words of Martin Luther King, Jr., "of all forms of inequality, health care disparities are the most shocking and inhumane." 4 Recognizing these words and distinctions, which have become more salient in the age of Covid-19, we have introduced new requirements for equity in health care accreditation.
As I said, they are advisory, not prescriptive. It aims to help organizations align their performance improvement initiatives to accelerate improvements in specific areas. There is only one standard with six performance elements. These include (1) appointing a health equity leader within the organization, who may be an additional responsibility of the leader, (2) assessing health-related social needs, (3) stratifying the quality and safety of health data. selecting an organization, (4) creating an action plan in which the organization sees opportunities, (5) evaluating the effectiveness of the plan, and (6) providing information to stakeholders.
You can see that these six performance elements that are part of the standard align with what an organization can do, and what we believe should be done, to help address some of the persistent disparities in health care. It is not intended to be a stand-alone activity that requires study for testing, but rather integrates organizational PI (performance improvement) with the inspiration, improvement, and accountability provided by The Joint Commission.
Li:
I really like these six steps because there is a danger that organizations will only talk about DEI (diversity, equality and inclusion) and not take the steps to follow them. These six steps seem absolutely necessary, not sufficient, to ensure real progress. The second is tougher: environmental sustainability. Isn't this news to the Joint Commission and institutions like health promotion?
Pearly.
Yes! But sustainable development, particularly decarbonisation, is at the heart of the public health agenda, especially as climate change directly and disproportionately affects the health and well-being of people around the world. Here are three key facts. [First, if worldwide health care were a country, it would be the fourth or fifth largest polluter. 5 However, the United States is singularly responsible for more than a quarter of the world's [greenhouse gas] emissions in health care. 6:00 a.m
Second, climate change is a health issue. It worsens heart disease, respiratory disease, increases water-borne diseases, and even deprives other people of clean water. [Third,] climate change is a health equity issue because people with fewer resources are less able to offset its effects.
We assembled a technical advisory committee to accomplish two things. First, we want to initiate a managed standard that will encourage health systems to reduce their carbon footprint, and second, a technical advisory group will help us revise our standards to ensure that our standards do not require large consumption. The standard interpretation [could] be seen as encouraging disposable and similar use, so we want to ensure that our standards do not inadvertently encourage overconsumption. We want to be proactive and responsive in this regard. I will tell you two more things. First, there are already ESG (Environmental, Social and Corporate Governance) requirements from the Securities and Exchange Commission for investor-owned entities, and we know that what's happening is a bit like Sarbanes-Oxley [financial reporting]. , as well as screens for non-profit organizations. This helps organizations prepare for what works for one group and not for another.
Second, as they say at Microsoft, "we eat dog food." On July 7, we signed the White House Health Sector Climate Pledge to reduce carbon emissions by 50% by 2030 and commit to zero emissions by 2050. I think not only as a health leader, but as a parent leader.
If we look at the events that have affected our world in terms of climate, is it floods in India damaging crops, is it disease in the United States due to climate change or recent storms? If we don't deal with this problem, we can surely leave our children with a more fragile and broken world.
We have an opportunity to make a big difference in healthcare, and the United States accounts for about 9.5% of that carbon footprint. 5 Finally, I'll show you some things we can do, like reduce the flow rate of isoflurane, desflurane, nitrous oxide, etc. they also save money. This is good, but it also has value in terms of social responsibility and financial value.
Li:
This long-term view of what excellence means in healthcare makes sense. The third priority is short-term, but on everyone's mind, and you also describe it as a sustainability issue: workforce burnout. I know you've been waiting for my question. What can the Joint Commission do, since it is already on the minds of the people who run health care organizations?
John Perlin.
Tom, as you researched, commented and discussed, health stress was there before the pandemic, but it certainly got worse during the pandemic, and that stress contributed to the Great Recession. Today, we all struggle with unprecedented staffing shortages and related challenges.
I feel this creates a triple whammy, pitting the interests of patients, communities and healthcare professionals against each other. Patients have the right to safe and quality care. People have the right to access various health services. And medical workers have the right to healthy working conditions. This is an equation with three variables. You cannot be satisfied with one and not the other.
Staffing is a complex issue. There is no way to fix this. It cannot be decided by a Community Commission or one person. We must all agree that the pandemic has brought significant attention to the need for more qualified healthcare professionals to meet the demands of patients, but we must also explore new models of healthcare delivery.
However, the Joint Commission wants to do something now. Based on this working environment, having personally experienced the request, I recently announced that we are starting to review all of our requests from top to bottom. Remember that the Joint Commission standards come in part from us, and there are regulators that came through CMS, OSHA, the National Fire Protection Association, etc.
In addition to all these standards, I have announced a major review to determine whether these requirements touch on the main issues of quality and safety, whether they are redundant with other standards, and frankly, whether the juice is worth it. whether the time and resources required to meet these requirements are commensurate with the perceived benefits to patient care and health outcomes.
In short, our goal is to reduce the already excessive burden on healthcare professionals and facilities. We believe this much-needed review will allow us to focus more on the steps that will truly move the needle toward high-quality, high-performance healthcare.
Li:
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