1 00:00:00,000 --> 00:00:02,319 Hi, everyone. This is Lucas Voss with Becker's 2 00:00:02,319 --> 00:00:04,000 Healthcare. Thanks so much for tuning in to 3 00:00:04,000 --> 00:00:06,960 the Becker's Healthcare podcast series. Fantastic to have 4 00:00:06,960 --> 00:00:10,160 you. Today, we're talking about improving health care 5 00:00:10,160 --> 00:00:12,880 quality and safety. And joining me for today's 6 00:00:12,880 --> 00:00:15,304 discussion is doctor Ken Grubbs. Fantastic to have 7 00:00:15,304 --> 00:00:17,625 him. He's the vice president of accreditation and 8 00:00:17,625 --> 00:00:21,464 certification operations and chief nursing officer at Joint 9 00:00:21,464 --> 00:00:24,265 Commission. Yeah. Lucas, it's an absolute pleasure to 10 00:00:24,265 --> 00:00:26,585 be here. Yes. It's so fantastic to have 11 00:00:26,585 --> 00:00:28,684 you. For those that might not know you 12 00:00:28,744 --> 00:00:30,410 yet, could you just share a little bit 13 00:00:30,410 --> 00:00:31,929 about yourself and and your work in health 14 00:00:31,929 --> 00:00:34,170 care? Yeah. I'm happy to do that. I 15 00:00:34,170 --> 00:00:36,090 I I'm a nurse by background, naturally. Even 16 00:00:36,090 --> 00:00:38,090 in the title, you can understand that. But 17 00:00:38,090 --> 00:00:40,329 I started out as a nurse in a 18 00:00:40,329 --> 00:00:41,710 critical access hospital. 19 00:00:42,409 --> 00:00:43,149 I went, 20 00:00:43,530 --> 00:00:45,015 and really found that 21 00:00:45,494 --> 00:00:45,994 nursing, 22 00:00:46,375 --> 00:00:50,215 and emergency departments was my theme, clinically, and 23 00:00:50,215 --> 00:00:52,774 spent time doing that at the bedside. And 24 00:00:52,774 --> 00:00:55,254 then, gradually moved up through leadership and, 25 00:00:55,975 --> 00:00:56,954 spent some time, 26 00:00:57,335 --> 00:01:00,210 both clinically and operationally, at a large, healthcare 27 00:01:00,210 --> 00:01:02,149 system within The United States 28 00:01:02,530 --> 00:01:04,709 responsible for regulatory and accreditation, 29 00:01:05,490 --> 00:01:06,469 for the enterprise, 30 00:01:07,010 --> 00:01:08,689 and then also spent some time at the 31 00:01:08,689 --> 00:01:10,390 National Patient Safety Foundation. 32 00:01:10,930 --> 00:01:13,170 So great to have you. I wanna spend 33 00:01:13,170 --> 00:01:13,909 some time 34 00:01:14,314 --> 00:01:16,635 to talk about Accreditation three sixty. It's been 35 00:01:16,635 --> 00:01:18,954 sort of positioned as this new standard, this 36 00:01:18,954 --> 00:01:21,295 new all encompassing standard for accreditation. 37 00:01:22,155 --> 00:01:24,974 What makes this shift so important right now? 38 00:01:25,435 --> 00:01:27,435 And how do you really see it changing 39 00:01:27,435 --> 00:01:28,655 the way health systems 40 00:01:29,299 --> 00:01:31,159 experience the process of accreditation? 41 00:01:31,780 --> 00:01:34,500 Well, Accreditation three sixty is what I would 42 00:01:34,500 --> 00:01:37,140 say or we would say is, the leap 43 00:01:37,140 --> 00:01:38,040 into the future 44 00:01:38,500 --> 00:01:39,400 of what accreditation 45 00:01:40,020 --> 00:01:40,760 should be. 46 00:01:41,140 --> 00:01:43,984 It is a model where it's data focused, 47 00:01:44,765 --> 00:01:47,185 specifically on patient outcomes by example. 48 00:01:47,644 --> 00:01:50,125 But it's also a model that's supportive of 49 00:01:50,125 --> 00:01:51,825 organizations that are accredited 50 00:01:52,125 --> 00:01:53,344 through joint commission. 51 00:01:53,724 --> 00:01:55,504 We wanna make sure that we recognize 52 00:01:55,805 --> 00:01:58,859 the current environment within health care, that we 53 00:01:58,859 --> 00:02:02,799 are creating clarity around our standards and requirements, 54 00:02:03,420 --> 00:02:06,540 and creating that clarity also helps to reduce 55 00:02:06,540 --> 00:02:07,040 burden. 56 00:02:07,420 --> 00:02:09,180 And we have an obligation to do all 57 00:02:09,180 --> 00:02:12,620 of those things. We want Accreditation three sixty 58 00:02:12,620 --> 00:02:13,360 to represent, 59 00:02:13,784 --> 00:02:15,245 certainly, where organizations 60 00:02:15,705 --> 00:02:18,264 find value in accreditation from a patient safety 61 00:02:18,264 --> 00:02:19,485 and quality standpoint, 62 00:02:19,944 --> 00:02:22,044 and we remain focused on that collaborative 63 00:02:22,824 --> 00:02:25,224 engagement, because we're all here for the same 64 00:02:25,224 --> 00:02:27,485 thing, and that's the patient, and improving 65 00:02:27,909 --> 00:02:30,150 the outcomes for patients and the communities that 66 00:02:30,150 --> 00:02:32,310 are served within health care. So what it 67 00:02:32,310 --> 00:02:34,789 also does is it creates balance in terms 68 00:02:34,789 --> 00:02:36,550 of creating a higher standard, but at the 69 00:02:36,550 --> 00:02:37,770 same time also keeping 70 00:02:38,150 --> 00:02:41,110 clinicians in mind from an administrative burden and 71 00:02:41,110 --> 00:02:43,384 innovating at the same time. Yeah. Absolutely. 72 00:02:43,685 --> 00:02:44,164 So, 73 00:02:44,805 --> 00:02:45,544 by example, 74 00:02:46,164 --> 00:02:47,224 certainly the rigor 75 00:02:47,764 --> 00:02:50,584 of, of a joint commission accreditation 76 00:02:50,884 --> 00:02:52,344 process isn't changing. 77 00:02:52,965 --> 00:02:55,145 But, you can have rigor in a collaborative 78 00:02:55,205 --> 00:02:57,500 way, and that's the most important thing to 79 00:02:57,500 --> 00:03:00,159 take away from the messaging, if you will. 80 00:03:00,219 --> 00:03:01,360 You can have rigor, 81 00:03:01,979 --> 00:03:03,979 in a way that it also allows for 82 00:03:03,979 --> 00:03:05,039 performance improvement. 83 00:03:05,580 --> 00:03:07,500 And you can certainly do that in a 84 00:03:07,500 --> 00:03:08,879 way that, not only 85 00:03:09,385 --> 00:03:10,365 in the accreditation 86 00:03:10,665 --> 00:03:13,944 process do we identify where risk might be, 87 00:03:14,264 --> 00:03:17,064 from an organization standpoint as it relates to 88 00:03:17,064 --> 00:03:17,564 patients, 89 00:03:18,105 --> 00:03:19,405 but what are solutions 90 00:03:19,865 --> 00:03:22,825 when we identify risk? And, we're moving into 91 00:03:22,825 --> 00:03:24,620 that space in 2026 92 00:03:24,620 --> 00:03:27,120 to say, if we identify an opportunity, 93 00:03:27,659 --> 00:03:29,900 we also want to talk about where there 94 00:03:29,900 --> 00:03:32,000 are solutions with that opportunity. 95 00:03:32,460 --> 00:03:34,540 And, oh, by the way, here's all of 96 00:03:34,540 --> 00:03:36,525 the data that can help support you from 97 00:03:36,525 --> 00:03:39,984 a performance improvement perspective. Again, focusing on patients, 98 00:03:40,364 --> 00:03:42,924 and focusing on the burden that might be 99 00:03:42,924 --> 00:03:44,384 created. And a critically 100 00:03:44,844 --> 00:03:47,824 important part of that is everyone just understanding 101 00:03:47,884 --> 00:03:50,659 what the standards and requirements are. You know, 102 00:03:50,659 --> 00:03:52,819 as we went through this process, the most 103 00:03:52,819 --> 00:03:55,159 important thing that we took away is that 104 00:03:55,300 --> 00:03:58,099 not everyone understood what the requirements are, and 105 00:03:58,099 --> 00:04:00,819 this really is an attempt to really get 106 00:04:00,819 --> 00:04:01,319 to 107 00:04:01,699 --> 00:04:02,840 what are the requirements. 108 00:04:03,355 --> 00:04:05,194 Let's get rid of the ones that are 109 00:04:05,194 --> 00:04:05,694 redundant, 110 00:04:06,235 --> 00:04:08,635 no longer make sense, if you will, and 111 00:04:08,635 --> 00:04:10,635 let's consolidate them in a way that it 112 00:04:10,635 --> 00:04:11,135 resonates 113 00:04:11,435 --> 00:04:13,775 in a way that individuals can understand. 114 00:04:14,314 --> 00:04:16,795 So through that process, by example, down from 115 00:04:16,795 --> 00:04:18,154 roughly 1,500 116 00:04:18,154 --> 00:04:20,150 requirements to 700. 117 00:04:20,370 --> 00:04:22,389 And the intent is to add clarity. 118 00:04:23,009 --> 00:04:25,330 And why that's important, I'll just add one 119 00:04:25,330 --> 00:04:27,029 more thing here, as is sometimes 120 00:04:27,810 --> 00:04:30,370 the burden is created through the interpretation of 121 00:04:30,370 --> 00:04:33,055 what the requirements are. And we really wanna 122 00:04:33,055 --> 00:04:35,454 go after that. And that's a significant reduction. 123 00:04:35,454 --> 00:04:37,375 It's it's great to hear those numbers. I 124 00:04:37,375 --> 00:04:38,894 I wanna touch a little bit more on 125 00:04:38,894 --> 00:04:40,415 some of the initiatives, right, that are heading 126 00:04:40,415 --> 00:04:42,254 into 2026, some of the new things you've 127 00:04:42,254 --> 00:04:44,654 mentioned again, a focus on on data, a 128 00:04:44,654 --> 00:04:46,194 focus on data driven performance. 129 00:04:47,170 --> 00:04:49,089 Let's touch on the national performance goals a 130 00:04:49,089 --> 00:04:50,310 little bit more. And, also, 131 00:04:50,610 --> 00:04:52,930 the safest program, which launches Yeah. Launches here 132 00:04:52,930 --> 00:04:55,170 in q one in 2026, which is coming 133 00:04:55,170 --> 00:04:56,069 up very rapidly, 134 00:04:56,610 --> 00:04:58,710 what opportunities do you see there 135 00:04:59,089 --> 00:05:00,470 to help health systems 136 00:05:00,865 --> 00:05:04,084 to create more improvement and more collaboration? Yeah. 137 00:05:04,305 --> 00:05:07,104 We're extremely excited by the SAFEST program, and 138 00:05:07,104 --> 00:05:08,544 I know we'll talk about that just in 139 00:05:08,544 --> 00:05:10,625 a couple of moments. But going to the 140 00:05:10,625 --> 00:05:14,305 national, performance goals, the intent there is to 141 00:05:14,305 --> 00:05:14,805 absolutely, 142 00:05:16,439 --> 00:05:19,480 send a message on areas that clinically need 143 00:05:19,480 --> 00:05:21,580 to be focused on, and sometimes, 144 00:05:22,680 --> 00:05:25,080 we will hear that Joint Commission goes above 145 00:05:25,080 --> 00:05:28,439 and beyond what CMS conditions of participation or 146 00:05:28,439 --> 00:05:30,855 conditions for coverage requirements are. 147 00:05:31,415 --> 00:05:33,895 These national performance goals, if you will, are 148 00:05:33,895 --> 00:05:36,555 things that are so ingrained in clinical practice, 149 00:05:37,415 --> 00:05:40,375 and so important to safety that they're truly 150 00:05:40,375 --> 00:05:43,735 not above clinical practice expectations. So when we 151 00:05:43,735 --> 00:05:46,899 talk about national performance goals, and let's just 152 00:05:46,899 --> 00:05:49,319 take goal number one as an example, that 153 00:05:49,459 --> 00:05:52,339 patients receive the right care at the right 154 00:05:52,339 --> 00:05:55,159 time. That's where we talk about critical results. 155 00:05:55,220 --> 00:05:57,000 That's where we talk about throughput 156 00:05:57,539 --> 00:05:59,879 of patients, and no matter where they're located 157 00:06:00,019 --> 00:06:00,919 in an organization, 158 00:06:01,564 --> 00:06:03,644 that they receive the care that they should 159 00:06:03,644 --> 00:06:04,144 receive. 160 00:06:04,685 --> 00:06:07,985 And that resonates throughout the national performance goals. 161 00:06:08,044 --> 00:06:10,844 No one, by example, would ever say, let's 162 00:06:10,844 --> 00:06:13,485 stop marking surgical sites, or let's don't do 163 00:06:13,485 --> 00:06:15,900 time outs. And that's the reason why we 164 00:06:15,900 --> 00:06:18,480 put the focus on safe procedural and surgical 165 00:06:18,540 --> 00:06:20,160 time outs, because we know 166 00:06:20,460 --> 00:06:22,879 that there's absolutely still opportunities. 167 00:06:23,340 --> 00:06:26,379 And the way we package these together, 168 00:06:27,865 --> 00:06:28,365 historically, 169 00:06:28,745 --> 00:06:31,144 the requirements would have been in different chapters, 170 00:06:31,144 --> 00:06:33,324 and would have been confusing, if you will. 171 00:06:33,464 --> 00:06:35,805 Now we've brought them together in a way 172 00:06:35,865 --> 00:06:37,084 that it makes sense 173 00:06:37,464 --> 00:06:37,964 clinically, 174 00:06:38,425 --> 00:06:39,884 it makes sense operationally, 175 00:06:40,430 --> 00:06:42,910 and it helps clarify the intent and allows 176 00:06:42,910 --> 00:06:45,009 everyone to be focused on the right thing. 177 00:06:45,230 --> 00:06:46,370 Again, it helps 178 00:06:46,670 --> 00:06:49,250 balance. It creates balance in itself. 179 00:06:50,029 --> 00:06:50,770 The safest 180 00:06:51,149 --> 00:06:53,914 program to, just to elaborate a little bit 181 00:06:53,914 --> 00:06:55,834 more on that as well, it really creates 182 00:06:55,834 --> 00:06:56,574 an opportunity 183 00:06:57,274 --> 00:07:00,154 for organizations to be proactive and actually learn, 184 00:07:00,154 --> 00:07:02,175 okay, what can we do better in educational 185 00:07:02,634 --> 00:07:03,134 opportunity? 186 00:07:03,514 --> 00:07:05,514 Why is the safest program so important for 187 00:07:05,514 --> 00:07:08,930 this? Well, as as I moved into joint 188 00:07:08,930 --> 00:07:10,930 commission from a leadership perspective, and then I 189 00:07:10,930 --> 00:07:12,610 would say this for all of our leaders, 190 00:07:12,610 --> 00:07:14,449 one of the most important things to do 191 00:07:14,449 --> 00:07:15,430 was to listen. 192 00:07:16,290 --> 00:07:18,529 And then once we listened, we needed to 193 00:07:18,529 --> 00:07:20,069 take action. And it was 194 00:07:20,665 --> 00:07:21,944 wonderful to hear, 195 00:07:22,345 --> 00:07:23,805 throughout those experiences, 196 00:07:24,185 --> 00:07:25,564 there were organizations, 197 00:07:26,345 --> 00:07:28,264 as would be true in healthcare, we're all 198 00:07:28,264 --> 00:07:30,025 good people coming to work to do the 199 00:07:30,025 --> 00:07:32,824 right thing, and we wanna learn. We're all 200 00:07:32,824 --> 00:07:34,764 vested in, or invested in, 201 00:07:35,329 --> 00:07:37,349 improving the healthcare for all, 202 00:07:37,970 --> 00:07:40,849 in our communities. And what we heard is 203 00:07:40,849 --> 00:07:41,349 organizations 204 00:07:41,970 --> 00:07:43,189 wanted to absolutely 205 00:07:43,569 --> 00:07:44,069 know 206 00:07:44,449 --> 00:07:46,629 if there was a risk or an opportunity 207 00:07:46,769 --> 00:07:48,550 from a quality or safety perspective. 208 00:07:49,074 --> 00:07:51,714 They wanted to know where organizations were doing 209 00:07:51,714 --> 00:07:52,375 it right. 210 00:07:52,754 --> 00:07:55,154 And, they wanted to know those whether we 211 00:07:55,154 --> 00:07:58,435 call them leading practices, performance strengths, whatever it 212 00:07:58,435 --> 00:08:00,915 might be, they wanted to know examples of 213 00:08:00,915 --> 00:08:03,495 those. So we were obligated to say, imagine, 214 00:08:03,970 --> 00:08:05,829 we have over 23,000 215 00:08:06,129 --> 00:08:07,269 accredited programs, 216 00:08:07,810 --> 00:08:10,769 just the knowledge and opportunity that we have 217 00:08:10,769 --> 00:08:11,589 to disseminate 218 00:08:12,209 --> 00:08:13,350 some of those leading, 219 00:08:13,730 --> 00:08:17,189 practices or performance strengths. Not only did organizations 220 00:08:17,569 --> 00:08:20,035 want to know those, but for those that 221 00:08:20,035 --> 00:08:22,915 are performing well, they feel that they're obligated 222 00:08:22,915 --> 00:08:25,314 to help share those as well. And that's 223 00:08:25,314 --> 00:08:27,314 the great story around this is it really 224 00:08:27,314 --> 00:08:28,694 sets up a platform 225 00:08:29,235 --> 00:08:30,774 to allow that to happen. 226 00:08:31,349 --> 00:08:31,849 Absolutely. 227 00:08:32,389 --> 00:08:34,629 Ken, such a pleasure to have you. Anything 228 00:08:34,629 --> 00:08:36,230 else to add that we haven't touched on 229 00:08:36,230 --> 00:08:38,549 that might be important for our listeners? Well, 230 00:08:38,549 --> 00:08:40,549 I would say to all the listeners, number 231 00:08:40,549 --> 00:08:43,450 one, joint commission is here to be collaborative. 232 00:08:43,909 --> 00:08:46,394 We are all invested in the same thing, 233 00:08:46,394 --> 00:08:48,235 and that is the patient and the care 234 00:08:48,235 --> 00:08:49,454 of patients and communities. 235 00:08:49,834 --> 00:08:52,954 And to that end, please take time, go 236 00:08:52,954 --> 00:08:55,274 back, thank your teams for what they do 237 00:08:55,274 --> 00:08:57,754 each and every day in providing care to 238 00:08:57,754 --> 00:09:00,600 the patients you serve, we serve, and the 239 00:09:00,600 --> 00:09:03,000 communities that you serve. Ken, thanks for taking 240 00:09:03,000 --> 00:09:04,600 the time. It's great to have you. Thank 241 00:09:04,600 --> 00:09:06,600 you. Absolutely. And we also want to thank 242 00:09:06,600 --> 00:09:08,759 our podcast sponsor, the Joint Commission. You can 243 00:09:08,759 --> 00:09:10,839 tune into more podcasts from Becker's Healthcare by 244 00:09:10,839 --> 00:09:14,779 visiting our podcast page at beckershospitalreview.com.