Master Your Healthcare Career
Master Your Healthcare Career
Dr. Jonathan Perlin of The Joint Commission on Revolutionizing Healthcare
Join us as we welcome Dr. Jonathan Perlin, President and CEO of The Joint Commission, the world-wide leader in accreditation of healthcare institutions.
The session explores and provides a personal journey, as a physician and researcher who served as Under Secretary for Health and CEO of the Veterans Health Administration. After his work with the VHA, Dr. Perlin later became the President of Clinical Operations and Chief Medical Officer with HCA Healthcare. Dr. Perlin provides valuable insights to early careerists entering the world of a profession that balances health equity, environmental sustainability, learning and performance integration.
To learn more about Dr. Jonathan Perlin: https://www.jointcommission.org/who-we-are/joint-commission-officers-group/jonathan-b-perlin/
Well, Melissa, thank you very much for that introduction and a warm welcome today to John Perlin. John, thanks very much for joining the podcast today.
Speaker 2:It's a delight to be here with you, Anthony. Thanks to you and Kami for all that you do.
Speaker 1:Thank you. Well, john, let me start out. You know, I know everyone in health care knows what the Joint Commission is, but this podcast and this episode is particularly target sometimes to people who are looking at starting their careers in healthcare management and are thinking about growing in there. So I'm going to ask you one of the questions that you probably don't get asked a lot, which tell me about the Joint Commission. What does it do, what's its role, what's its purpose?
Speaker 2:Well, thanks for that question. It's really an important question and while those of us who've been in healthcare certainly know the Joint Commission, I doubt that many people know why the Joint Commission is called the Joint Commission. But in 1951, jointly, the American College of Surgeons wanted to continue what it had started in 1913, which was inspecting hospitals for technical capacity, for quality. In fact, ernest Codman, one of the founders of the quality movement in the early 20th century, started the American College of Surgeons and the predecessor Physicians ran hospitals until World War II. They got drafted to theater.
Speaker 2:There was a deficit of physicians and the early 50s was the rise important to Cammie of professional healthcare management. But with the depletion of physicians and physician executives, the American College of Surgeons turned to the American Medical Association, the American College of Physicians, the American Dental Association and the American Hospital Association and jointly established the organization we know today as the Joint Commission. It's the largest accreditor of hospitals in the United States and Joint Commission International operates in 86 countries. With the advent of the Medicare legislation in 1965, accreditation became required for hospitals to participate in those federal programs, which means they couldn't be paid unless they were accredited and organizations like the Joint Commission were deemed to have the authority of CMS to assure that certain marks of quality and safety are foundationally in place.
Speaker 1:John, the intersection with CAMI to me is just amazing because it's the same kind of time period the formation of Medicare and Medicaid and which really kind of kicked in the importance of the Joint Commission.
Speaker 1:Also, in 1968, CAMI started too and that was really kind of designed with the same purpose to make sure students are well-prepared to lead in an increasingly complex world. You mentioned Codman and I think that's a fascinating kind of link for me. Prior to the session, I was just looking at your LinkedIn profile and your own background and you listed three skills and, John, I kind of got a kick out of it because, as I think about you multi-skill, but you listed three skills and those are interesting to me telling. One was data analysis, one was clinical research and one was electronic health records Data analysis, clinical research and electronic health records and it was fascinating to me when I thought about that, because you're an MD and a PhD and basically, John, you're a scientist, You're someone who continuously explores how data can better interpret the world and make it a better place. And to me, the Joint Commission, that's what it's all about. It's the continuous improvement of quality.
Speaker 2:Well, we think it's a really important organization and I came here to really give back after a career that I've been very blessed to have had. It was interesting Joint Commission was recruiting for a new CEO who had academic background and indeed, as you mentioned, I have a PhD but I turned my attention to health services research because I kept asking the question why things didn't work better. They wanted someone with senior government experience and I think running the VA health system counts for that and they wanted someone with operational experience. And you know, being at HCA for over 15 years and leading the clinical enterprise really gave me that you know boots on the ground, operational experience as well, and so being able to bring that to the Joint Commission has been really important, because we work closely with CMS, we work closely with the major organizations that I mentioned that were the founders of the Joint Commissions, and the truth of the matter is is that in our careers there's never been a more complex time in healthcare.
Speaker 2:It's a tough time for healthcare organizations, it's a tough time for healthcare workers and you know, whether it's you and I as patients or advocating for family or friends, we still don't have the type of quality that we want, and one of the things I'm most proud of in the early stages of my tenure here at Joint Commission is that we've eliminated 400 standards that we viewed to be not evidence-based, redundant juice, not worth the squeeze.
Speaker 2:And we only have one new standard, and I'll come to that. Um, and we only have one new standard, and I'll come to that, but um, the truth of the matter is there are other ways to get accredited. Um, we want to put the focus on those things that count. I know it's often attributed to Einstein, but it really is potentially attributable to many that old saying not everything that counts is measured and not everything that's measured counts. Um, we want to make sure that those things that get measured count, and that's the basis for our HELP agenda, which is an acronym for health, equity, environmental sustainability, learning, healthcare, which is really, at this moment, about the responsible use of AI and performance integration, making the survey process much less performative and much more integrated with the realities of operations. Today.
Speaker 1:And John, I think that's where you and I serve a common philosophy me and Kami with the we accredit graduate healthcare management education programs and you with the Joint Commission, which is we're not out there with a clipboard checking off, going met, not met, you know. But really our purpose, and our both your and my purpose is how do we make institutions better, how do we give them the tools and the knowledge to become better, with the overall, you know, guiding principle, how do we make our society better and healthcare better and the communities better?
Speaker 2:Yeah, well, first let me just say what a privilege it is to partner on the CAMI Joint Commission Sustainability Fellow, and I know we'll have a chance to talk about sustainability because it's a passion for both of us and our organizations. But you're right, what CAMI sees across health management, professional education, allows not only individual institutions to be better, but it creates the world's best library of practices, of leading practices, that can elevate all. Being in 86 countries and the opportunity to learn this works, this doesn't work, or how did they do it, how did they do that in a low resource environment, is really one of the great opportunities to bring evidence to the practice of healthcare and one of the privileges of the kinds of roles we have in our organizations seeing people really elevating the practice of health administration, the practice of healthcare, to its highest levels.
Speaker 1:It's so true, john, it's not just you know. Here's what we know in the United States, and how do we get better. But what's going on globally? What are people doing better elsewhere? How can we learn, how can we improve and how can we help other places get better as well too?
Speaker 2:Well, you know, when I first came on board, I did a bit of a listening tour and went around to some really prominent organizations and some smaller organizations and you know the message was the same. It's that why aren't you sharing best practices? Why aren't you helping us with benchmarking? Why aren't you kind of demystifying the accreditation process? Now let me dissect that a little bit.
Speaker 2:About two-thirds, 75% of the survey we have to do any accrediting organization has to do is based on the Centers for Medicare and Medicaid Services or CMS's conditions of participation, and those standards that are required come not only from CMS but are consolidated from a variety of sources. For example, the infamous water bottles and not having them in clinical areas that's OSHA, that's for health worker protection, the penetrations above ceiling tiles to prevent the spread of fire that's from the National Fire Protection Act, and so those things are structured by CMS. But we really get to bring creativity in working with those organizations that are part of the Joint Commission. Accredited family is really in things that we know we have great opportunities, and that's again the health agenda, health equity, environmental sustainability, learning and AI, and really performance integration is about linking the have-to-dos of accreditation with the want-to-dos of the operators' priorities at their own institutions.
Speaker 1:Right, john, let me go to sustainability, because you mentioned it a couple times right now and you and I had lunch I guess it was a little over a year ago and you brought back the Hippocratic Oath to me and it was first do no harm. And I love repeating it and giving you credit for reminding me of it too within CAMI when we talk about sustainability first do no harm. You've brought an interesting kind of focus to joint commission kind of talk about why you've done it and what you hope to accomplish through it.
Speaker 2:Well, a lot of this focus comes from the real world of providing care. Let me just digress for a moment and talk about health equity. You know, martin Luther King famously said in 1966 at the Medical Committee for Human Rights of all the forms of inequality, injustice in health is the most shocking and most inhuman. He didn't say inhumane, he didn't say it was cruel, he said it was beneath humanity. And sadly, nearly 70 years later, those words are still true. The age-adjusted mortality rates for African-American versus white are over twice as high and, using the OMV categories, american Indian and Alaskan Native, even higher. And oh, by the way, the cost of disparities is substantial. Today, we spent a third of a trillion dollars because of disparities in healthcare and by 2040, trillion dollars because of disparities in health care. And by 2040, that number, that cost notwithstanding, the human toll rises to a full trillion dollars.
Speaker 2:I saw the dislocations from care during COVID, my health system, we had virtually eliminated maternal mortality in women of color. In fact, in two years, 2018 and 2019, no women of color succumbed, which is extraordinary against the backdrop of a three to 400% greater risk for mortality in women of color. And in 2020, with the advent of COVID, 19 women showed up to the emergency room, pregnant, ready to deliver and at death's door. And it wasn't just COVID, it was dislocation from care, it was the fragmentations in our health system, and what was always unacceptable really to me became intolerable. So that was at the top of the agenda and I promised myself that, given the opportunity to lead Joint Commission, domestically, internationally, that would be a focus. Now, what may not be apparent is that there is a direct link to environmental sustainability and the impact of healthcare. It's really interesting. First, let's jump back for a moment. In 2021, the British Medical Journal partnered with over 200 other journals around the world, listing climate change as the number one threat to health, and I defy anyone to go to a healthcare organization and look at the mission. And I guarantee that mission says improve health, improve lives. And I guarantee that mission says improve health, improve lives. And the fact that healthcare is a major emitter. And, considered a country, it would be the fifth most polluting country on the planet. And if the United States were a state in that country, well, we're overachievers. We're 27% of the worldwide footprint and, on any given day, 9% of our carbon footprint in the United States comes from healthcare.
Speaker 2:It's a matter of health. There are diseases that used to be called tropical diseases. They're now endemic. They're now found each and every day throughout the continental US. For example, things that I didn't study much for in medical school because I thought I'd never see them Chickangunya, dengue Every state south of the Canadian border has them. Now it's a matter of health equity. The people who are most vulnerable to bad health outcomes can't buy their way out of harm's way Safety. We know that, at the very times that cities and individuals need health care, many of those health care organizations are offline, and so we've got to build resilience. As TS Chan School of Public Health at Harvard points out, four out of five primary care clinics were closed for at least one day in the last three years because of extreme weather events directly attributable to climate change, so that's why we're focused on these things.
Speaker 1:Yeah, john, it's just an amazing kind of set of statistics and the place that we're in right now where you're you know that focus is so important. I look at sustainability in the same way and I think how do we educate our students to become more aware of the issues and the impact on sustainability? And when you and I talked about that again a little over a year ago, we came up with this idea of a fellowship, and it was a fellowship sponsored by the Joint Commission in coordination with CAMI, and I'll let you talk a little bit about it because I know you're incredibly proud of it.
Speaker 2:Well, I am proud of it. You and I should both take pride. The inaugural recipient of the fellowship is Sadie Joba, a young woman from Rush University who wants to make a career of studying and improving sustainability in healthcare and, by the way, we'll be recruiting again and it's such a privilege to partner with you on this. But I need to really throw credit your way because, as I go around, not only to healthcare organizations but to healthcare training organizations, health management programs, I see now that, thanks to the Cami influence, sustainability is increasingly a part of the curriculum and it's something that particular younger individuals are very interested in. Did you know that, according to the Robert Half Company, over 50% of individuals between 18 and 34 do not want to work for organizations that don't have a proactive commitment to environmental stewardship? So the inconsistency with the mission of health care, the opportunity to improve health care, the opportunity to improve health and equity this is a compelling area and an important new discipline or subdiscipline of health administration and one, frankly, that's inescapable for the foreseeable future.
Speaker 1:I see it, john, as you and I tapping into that vein and going yes, that's an important vein, go with it and make change in health care. Change in health care. And you know it's. Sadie is a fabulous first recruit from Rush University, someone who is so dedicated to the issues of sustainability, improvement of health care, quality improvement and, like we, we were really fortunate, and I think anyone listening to this, you can go to the CAMI website and learn more about the CAMI Joint Commission Fellowship for Sustainability and how to Look Live Again the partnership is just amazing to me, john, thank you very much for that.
Speaker 2:Well and we're learning as well and we appreciate Sadie being the pioneer in this area. I was just speaking with John Balbus at the Office for Climate Change and Health Equity OCHE at HHS and Health Equity Ochi at HHS. He indicated that the office would welcome future fellows to have an experience in the office as well. So this is an opportunity for individuals to really meet the leaders around the country working on sustainable health care.
Speaker 1:Yeah, john, I want to go back a little bit because you know again, besides your MD and your PhD, at one point you were also an MHA student at the Virginia Commonwealth University, a CAMI accredited program, and I know part of your passion for CAMI kind of comes from that pedigree. If you would, when you were you know again, I'll kind of ask you when you were back in that program at that time and I know you, if I'm correct, you also had your MD, like you were, you were. You went back on the executive kind of track on that. Why did you do it?
Speaker 2:Well, that's a great question. I didn't intend to go into health administration. Truth be known, an intent to go into health administration. Truth be known, I did the combined MD-PhD program and I was headed toward a career in molecular neurobiology not the obvious course to health administration. But my very first patient was a heart transplant patient smoking. 10 days after his transplant, my wife, a pediatrician, turned to me and said you realize, every kid in Richmond could have been immunized for the cost of that transplant.
Speaker 2:In any event, short story is that I got sent to talk to the dean. The dean said well, it's difficult as a state school for us to take on big tobacco, but he said you know, we would support students who wanted to take this on and, working with faculty, we became tobacco-free in the next year and I learned this empowering lesson, which is that everything that brought me to want to be a doctor, to want to improve health, I realized could be amplified if you had a policy lever. And I had an absolutely wonderful mentor, a new chief of medicine, a guy named Richard Wenzel, one of the founders of the Society for Hospital Epidemiology of America, who said we need to approach quality and safety using mathematical and epidemiologic tools. He said you need to get trained, and so he let me, as chief resident and as a junior faculty member, join the executive program at Virginia Commonwealth University and I retread as a health services researcher. I actually used the opportunity of my health administration capstone project to write a business plan for an interstate telehealth network and do some other things, and so I have an extreme debt of gratitude to VCU broadly, but also to the health administration program.
Speaker 2:Now, I will tell you at that point, having, as you indicated, already been become a doctor, I was working really hard and the MHA executive track was, I think, harder because I had a day job and I, you know, got up every morning at three o'clock, studied till five o'clock for two years in that program.
Speaker 2:But it was absolutely the best possible career decision that I could have made, and so I want to congratulate VCU on their 75th anniversary as a health administration program, tracing their roots to exactly that period of time that led to the formation of the Joint Commission, the formation of CAMI, and you know and I've gotten to learn a lot about other health administration programs too I have the privilege of being on the National Advisory Board to Columbia Mailman's Health Policy and Management Program program. And you know it's just so interesting to see the traces of CAMI, the preparation for their accreditation visits and, you know, to see the influence that organizations like CAMI and Joint Commission can have in terms of giving a little boost to things that we know are important, like health equity and like sustainability.
Speaker 1:You hope, john, that everything you do is really kind of having an impact in some way, shape or form, and every now and then in your life you see little threads of it kind of occurring and you think, yeah, there's a little part in there that I had a function in. So I appreciate you kind of saying that VCU, one of the founders of CAMI, we started one of the original programs too. There are two other things I want to kind of point out. One of them was your role at the VHA as undersecretary, and what a critical time that was, because at that particular point VHA was starting with electronic health records and you had a huge part in that too. Vha was starting with electronic health records and you had a huge part in that too. It's hard to kind of think in the time of 2024 what life was like before electronic health records, but there was that point and the VHA at that particular juncture was really known for what it was accomplishing with EHR.
Speaker 2:Well, you know, I came into the VA as the chief quality officer and then held a number of jobs chief research officer, chief operating and then chief executive officer. But in that first role as chief quality officer, the Secretary of Veterans Affairs asked me if you could do one thing to improve safety, quality and value. What would it be and why? I said full deployment of an electronic health record. We can create systemness out of fragmentation VA has a large footprint but it's a giant country and that we could measure and mark progress. And I remember he gave me the go-ahead, said make it happen. And I remember that in about 2005 or so when I became the CEO before that, but when I was CEO undersecretary I got this call from the White House and the president says we've got a very special guest. Could you come over and show him that EHR thing? And you know, I didn't say I'm going to check my calendar. I said of course, and I go over and it turns out it's Bill Gates and he was very interested in the fact that we had a national health record. But he wasn't thoroughly impressed.
Speaker 2:Now, mind you, this was 2004, 2005-ish, and no one could track a patient from Washington DC to Washington State because there were no national data exchanges, there was no national electronic record except VA. He asked this question why aren't you learning? And, honestly, I didn't understand that. And if you go back to that period of time, we didn't have multi-terabyte hard drives sitting on our desk. We were talking megabytes, sometimes gigabytes.
Speaker 2:It wasn't until 2009, when the next President, obama, invited me to chair the Health IT Standards Committee, where I had this epiphany that it wasn't just about having information, be able to follow patients from Washington DC to Washington State. It was about really creating the basis for a learning health system, one that uses all data created for discovery and research, for improving quality and safety and for improving operations. And this, I think, is where VA is, where many systems are, where really, in my next role at HCA, have the opportunity to use data at scale to really learn and accelerate improvement. So it's been an exciting run with respect to health information and I think the most exciting is ahead with AI.
Speaker 1:Yeah, no, it's true. Talk about AI, I have to say I had, our whole team read Malik's book and I think you know how can we incorporate AI, both in terms of, you know, our accreditation standards, but also in terms of what we do just as part of our normal you know, standards of work, co-intelligence by Ethan Malek. What's the Joint Commission doing around AI?
Speaker 2:We're doing a lot around AI. During COVID, when we had a large health system, we had the largest data set and we wanted to share that with NIH and AHRQ for accelerating the understanding of COVID and its therapy. But we didn't have an underwriter's laboratory to say that our stewardship of the data was as responsible as it might be. So we started this past year releasing the Responsible Use of Health Data Certification, and it's about appropriate secondary uses of data Definition. Secondary use means using data other than for the original clinical purpose. So if I get a blood test, let's say a blood count, obviously the clinical information is the blood count, but the secondary uses may be in improving quality operations, safety, research, et cetera. And patients do have a right to know how their data might be used. And so we followed guidance from Health Evolution, which convened privacy experts, patient advocates as well as technical experts, and listed a number of criteria, and the very first organization received their responsible use of health data certification just this past month, and that was Inova Health System in Fairfax, virginia. But AI is obviously going to be defining. It is the defining technology of the century, and I live between two fears the fear, on the one hand, that we won't have guardrails to prevent misuse or bad things from happening, even unintentionally. But I have a greater fear is that we don't stifle the capacity to improve safety and quality with rigid over-regulation and legislation. And so I think the healthcare field needs to take its own lead, and so we had a convening in Washington recently, had majority and minority members of Congress with leadership in AI. We have the new ASTP or Assistant Secretary for Technology Policy, mickey Trabathy, speak at that as well as patient advocates, and you know, if there was a key message, it was patient at the center, but sub-messages were that we need to figure a path between those two barriers underregulation on the one side and over on the other.
Speaker 2:And I want to offer a bit of a framework. You know Michael Howell and Karen DeSalvo have a fabulous paper on what they call the three epochs, time periods of AI, and they sort of coexist. But epoch one is really the probabilistic models, the if-then statements. You know we already use those in healthcare. If your blood pressure is high, treat it, and we don't want to over-regulate that.
Speaker 2:Epoc-2 is deep learning, machine learning. So, for example, training a system to read mammograms They'd already show, but those systems can help perform low-volume radiologists who don't do enough mammography to really be at the top of their game. Flipping that around, though, it can also kind of reduce the rote work for very experienced, and the best of all worlds is where the hyper-experienced person has some workload sorting by the machine and then overreads for the really special cases, and we want a different level of regulatory oversight there. But really where it gets interesting is what comes to mind today when we think of AI is generative foundation or large language models, where the use case for the application of that engine may be very different than the data that is trained on, and that's where there have been some problems. Notoriously, an insurance company wanted to improve heart failure for minority patients and because the training data were biased, instead of ameliorating the bias, it amplified it. And this is part of where we see a role for certification in terms of endorsing three skill sets simultaneously the technical capacity to build a model, the domain expertise, for example heart failure, but also the cultural competence to know what are the biases or to have drift in the model if it's doing things that aren't appropriate.
Speaker 2:But let me just close with this with an anecdote. When I was at HCA, we trained a model to identify sepsis earlier Sepsis I know most people think of as an end stage of overwhelming infection, but it's really total body organ failure and every hour of delayed diagnosis or delayed recognition increases the chance of death by up to 8%. So time is life and on top of benchmark levels of sepsis response across 63,000 beds, we introduced an AI system, an algorithm, to detect the early warning signs. In the first 18 months we saved 8,000 lives, 8,000 individuals who went on to celebrate a new year, to welcome a grandchild, celebrate a birthday, and we didn't say your patient has sepsis. We used what I call a peanut butter and jelly approach. We said, hey, the machine sees A, b and C. Now this had the virtue of being understandable to clinicians and some of the greatest response back was not only that it saved lives, but the clinician said this is what makes using an EHR worthwhile and you know, I want to make sure that these opportunities exist to really magnitudinally improve healthcare.
Speaker 1:John, I remember working with you at HCA and that's where I first became familiar with you and I was with a company called Solution at that time and I just remember leaving HCA in awe of what you folks were doing, both in terms of how you used our data and some of our data sets and algorithms and stuff and how you incorporated that into HCA data. And I have to tell you it was one of I know we had a very small part in there in terms of doing what you're doing. We weren't the implication behind it, but I have to tell you the folks at Solution and myself personally, we're very proud to at least play a part in that and the work that HCA was doing.
Speaker 2:Well, as they say, it takes a village. Thank you for that part, and even more thank you for the important role you're playing now with CAMI, because we get to spread this gospel of a better world ahead. I think both of us share that, despite optimism about how we can make progress in some of these critically important areas.
Speaker 1:Oh, thank you, John. This is a conversation I can continue on for a long time and I know our lunch that we had probably, I think, lasted two and a half hours when we did it, just simply around this. But I really want to thank you very much for participating on this episode and I think for any of the early careerists out there or students considering healthcare, you know your message of optimism, hope and making a better world, I think, is really one that should resonate in what we want to do in healthcare.
Speaker 2:Well, thank you, anthony, for the privilege of being with you today, and let me also take the prerogative not only for thanking Cami you, Anthony, for the privilege of being with you today, and let me also take the prerogative not only for thanking Cami, but all of those health professions educators around the country. I mentioned two of the great institutions I get to work with VCU and Columbia, and so just to call out to the teams there, led by Paula Song at VCU and Michael Sparer at Columbia, you know I wouldn't have had the great opportunities that I've had in my life were it not for programs like yours. So thanks for doing what you do. It's rare that we get to say thank you to our teachers.
Speaker 1:Absolutely All right, John. Well, appreciate your time. I know you got important meetings to kind of go after this and thank you very much for being part of this. Take care.