Hi, everyone. This is Lucas Voss with Becker's
Healthcare. Thanks so much for tuning in to
the Becker's Healthcare podcast series. Fantastic to have
you. Today, we're talking about improving health care
quality and safety. And joining me for today's
discussion is doctor Ken Grubbs. Fantastic to have
him. He's the vice president of accreditation and
certification operations and chief nursing officer at Joint
Commission. Yeah. Lucas, it's an absolute pleasure to
be here. Yes. It's so fantastic to have
you. For those that might not know you
yet, could you just share a little bit
about yourself and and your work in health
care? Yeah. I'm happy to do that. I
I I'm a nurse by background, naturally. Even
in the title, you can understand that. But
I started out as a nurse in a
critical access hospital.
I went,
and really found that
nursing,
and emergency departments was my theme, clinically, and
spent time doing that at the bedside. And
then, gradually moved up through leadership and,
spent some time,
both clinically and operationally, at a large, healthcare
system within The United States
responsible for regulatory and accreditation,
for the enterprise,
and then also spent some time at the
National Patient Safety Foundation.
So great to have you. I wanna spend
some time
to talk about Accreditation three sixty. It's been
sort of positioned as this new standard, this
new all encompassing standard for accreditation.
What makes this shift so important right now?
And how do you really see it changing
the way health systems
experience the process of accreditation?
Well, Accreditation three sixty is what I would
say or we would say is, the leap
into the future
of what accreditation
should be.
It is a model where it's data focused,
specifically on patient outcomes by example.
But it's also a model that's supportive of
organizations that are accredited
through joint commission.
We wanna make sure that we recognize
the current environment within health care, that we
are creating clarity around our standards and requirements,
and creating that clarity also helps to reduce
burden.
And we have an obligation to do all
of those things. We want Accreditation three sixty
to represent,
certainly, where organizations
find value in accreditation from a patient safety
and quality standpoint,
and we remain focused on that collaborative
engagement, because we're all here for the same
thing, and that's the patient, and improving
the outcomes for patients and the communities that
are served within health care. So what it
also does is it creates balance in terms
of creating a higher standard, but at the
same time also keeping
clinicians in mind from an administrative burden and
innovating at the same time. Yeah. Absolutely.
So,
by example,
certainly the rigor
of, of a joint commission accreditation
process isn't changing.
But, you can have rigor in a collaborative
way, and that's the most important thing to
take away from the messaging, if you will.
You can have rigor,
in a way that it also allows for
performance improvement.
And you can certainly do that in a
way that, not only
in the accreditation
process do we identify where risk might be,
from an organization standpoint as it relates to
patients,
but what are solutions
when we identify risk? And, we're moving into
that space in 2026
to say, if we identify an opportunity,
we also want to talk about where there
are solutions with that opportunity.
And, oh, by the way, here's all of
the data that can help support you from
a performance improvement perspective. Again, focusing on patients,
and focusing on the burden that might be
created. And a critically
important part of that is everyone just understanding
what the standards and requirements are. You know,
as we went through this process, the most
important thing that we took away is that
not everyone understood what the requirements are, and
this really is an attempt to really get
to
what are the requirements.
Let's get rid of the ones that are
redundant,
no longer make sense, if you will, and
let's consolidate them in a way that it
resonates
in a way that individuals can understand.
So through that process, by example, down from
roughly 1,500
requirements to 700.
And the intent is to add clarity.
And why that's important, I'll just add one
more thing here, as is sometimes
the burden is created through the interpretation of
what the requirements are. And we really wanna
go after that. And that's a significant reduction.
It's it's great to hear those numbers. I
I wanna touch a little bit more on
some of the initiatives, right, that are heading
into 2026, some of the new things you've
mentioned again, a focus on on data, a
focus on data driven performance.
Let's touch on the national performance goals a
little bit more. And, also,
the safest program, which launches Yeah. Launches here
in q one in 2026, which is coming
up very rapidly,
what opportunities do you see there
to help health systems
to create more improvement and more collaboration? Yeah.
We're extremely excited by the SAFEST program, and
I know we'll talk about that just in
a couple of moments. But going to the
national, performance goals, the intent there is to
absolutely,
send a message on areas that clinically need
to be focused on, and sometimes,
we will hear that Joint Commission goes above
and beyond what CMS conditions of participation or
conditions for coverage requirements are.
These national performance goals, if you will, are
things that are so ingrained in clinical practice,
and so important to safety that they're truly
not above clinical practice expectations. So when we
talk about national performance goals, and let's just
take goal number one as an example, that
patients receive the right care at the right
time. That's where we talk about critical results.
That's where we talk about throughput
of patients, and no matter where they're located
in an organization,
that they receive the care that they should
receive.
And that resonates throughout the national performance goals.
No one, by example, would ever say, let's
stop marking surgical sites, or let's don't do
time outs. And that's the reason why we
put the focus on safe procedural and surgical
time outs, because we know
that there's absolutely still opportunities.
And the way we package these together,
historically,
the requirements would have been in different chapters,
and would have been confusing, if you will.
Now we've brought them together in a way
that it makes sense
clinically,
it makes sense operationally,
and it helps clarify the intent and allows
everyone to be focused on the right thing.
Again, it helps
balance. It creates balance in itself.
The safest
program to, just to elaborate a little bit
more on that as well, it really creates
an opportunity
for organizations to be proactive and actually learn,
okay, what can we do better in educational
opportunity?
Why is the safest program so important for
this? Well, as as I moved into joint
commission from a leadership perspective, and then I
would say this for all of our leaders,
one of the most important things to do
was to listen.
And then once we listened, we needed to
take action. And it was
wonderful to hear,
throughout those experiences,
there were organizations,
as would be true in healthcare, we're all
good people coming to work to do the
right thing, and we wanna learn. We're all
vested in, or invested in,
improving the healthcare for all,
in our communities. And what we heard is
organizations
wanted to absolutely
know
if there was a risk or an opportunity
from a quality or safety perspective.
They wanted to know where organizations were doing
it right.
And, they wanted to know those whether we
call them leading practices, performance strengths, whatever it
might be, they wanted to know examples of
those. So we were obligated to say, imagine,
we have over 23,000
accredited programs,
just the knowledge and opportunity that we have
to disseminate
some of those leading,
practices or performance strengths. Not only did organizations
want to know those, but for those that
are performing well, they feel that they're obligated
to help share those as well. And that's
the great story around this is it really
sets up a platform
to allow that to happen.
Absolutely.
Ken, such a pleasure to have you. Anything
else to add that we haven't touched on
that might be important for our listeners? Well,
I would say to all the listeners, number
one, joint commission is here to be collaborative.
We are all invested in the same thing,
and that is the patient and the care
of patients and communities.
And to that end, please take time, go
back, thank your teams for what they do
each and every day in providing care to
the patients you serve, we serve, and the
communities that you serve. Ken, thanks for taking
the time. It's great to have you. Thank
you. Absolutely. And we also want to thank
our podcast sponsor, the Joint Commission. You can
tune into more podcasts from Becker's Healthcare by
visiting our podcast page at beckershospitalreview.com.