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Becker’s Healthcare Podcast
Advancing Accreditation and Patient Safety: Inside Joint Commission’s Transformative Accreditation 360
00:09:17
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- [00:00]
A
Hi everyone. This is Lucas Vaz 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 healthcare quality and safety. And joining me for Today's discussion is Dr. Ken Grubbs. Fantastic to have him. He's the vice president of accreditation and certification operations and chief nursing Officer at Joint Commission.
- [00:22]
B
Yeah, Lucas, it's an absolute pleasure to be here.
- [00:25]
A
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 your work at health care?
- [00:33]
B
Yeah, I'm happy to do that. 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, went and really found that nursing in emergency departments was my thing 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 accreditation for the enterprise, and then also spent some time at the National Patient Safety Foundation.
- [01:11]
A
So great to have you. I want to spend some time to talk about Accreditation360. 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?
- [01:32]
B
Well, accreditation 360 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 want to 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 Accreditation360 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 healthcare.
- [02:32]
A
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.
- [02:42]
B
Yeah, absolutely. So by example, certainly the rigor 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 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. 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. 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 1500 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 want to go after that.
- [04:34]
A
And that's a significant reduction. It's great to hear those numbers. I want to 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 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 here in Q1 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?
- [05:04]
B
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 it. Joint Commission goes above and beyond what CMS conditions of participation are or condition 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 timeouts. And that's the reason why we put the focus on safe procedural and surgical timeouts, 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 confused using, 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.
- [06:45]
A
Again, it helps balance. It creates balance in itself. The safest program, too, 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? An educational opportunity. Why is this safest program so important for this?
- [07:06]
B
Well, as. As I moved into joint commission from a leadership perspective, and 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 want to learn. We're all vested in or invested in improving 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.
- [08:31]
A
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?
- [08:38]
B
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.
- [09:02]
A
Ken, thanks for taking the time. It's great to have you.
- [09:05]
B
Thank you.
- [09:05]
A
Absolutely. And we also want to thank our podcast sponsor, the Joint Commission. You can tune into more podcasts from Becker's Healthcare visiting our podcast page@beckershospitalreview.com.