The Joint Commission, Patient Parity, and New Initiatives with Dr. Ana Pujols McKee

This transcript of their discussion has been edited for clarity and length.

Mike Sacopulos: Recent events have called greater attention to racial and ethnic disparities in healthcare. Whether it is infant mortality numbers or vaccine hesitancy, we have all seen the unsettling reports. We will explore this important patient safety topic today with a national healthcare leader and key executive with The Joint Commission. This is a special episode of SoundPractice, so let's begin.

Ana Pujols McKee, MD, FACP, is the executive vice president and chief medical officer, chief diversity, equity, and inclusion officer of the Joint Commission. In this role, Dr. McKee represents The Joint Commission enterprise as she focuses on and develops policies and strategies for promoting patient safety and quality improvement in healthcare and leads The Joint Commission enterprise in meeting its goals of increasing diversity and inclusivity. Dr. McKee, thank you so much for joining me on Sound Practice.

Ana Pujols McKee: A pleasure to join you. Thank you for inviting me.

Sacopulos: Dr. McKee, you have a large portfolio of duties for The Joint Commission. Could you tell me how this plays out on a day-to-day basis?

McKee: The Joint Commission has been transforming itself to become, and is, an expert in performance improvement, and has patient safety expertise. Accreditation, yes, is the core business, which is the process of standardizing processes and policies. But the aim and the end game are quality improvement and safety. In that vein, my role is to oversee a group of experts, and there is no other unit like this in the world, of clinicians who are masters-prepared, who are totally devoted to event investigation. They do root cause analysis on over 900 events every year.

That's one of my areas, and the other area that I lead The Joint Commission is in physician engagement. We know that we've lost the attention of the physicians, especially the physician leaders. That we are viewed as a heavy regulator, and little value is seen to what the Joint Commission is trying to achieve. Changing that narrative has been my work for now a good 10 years, in educating and working with physicians, giving them the communication and the resources that see us more as a partner with the expertise that they can really rely on.

Sacopulos: You've had a very interesting and impressive path to your current position as physician leader. Could you please tell us a bit about your career, and the steps which led you to The Joint Commission?

McKee: I've always had my eyes on leadership, and leadership being the avenue to making change and improving healthcare. My focus started very early in my career. After my residency, I did some work as an affiliate member of the Robert Wood Johnson Fellowship Program to get some basic fundamental skills. Accounting, healthcare administration, et cetera. Beyond that, most of my training has been on-the-spot. I became the medical director for the Philadelphia Public Health Department's eight ambulatory facilities, and that gave me a huge opportunity to really build on leadership, building trust, and really focusing my work around quality.

I then became the chief medical officer for Presbyterian. There were some intermediate steps in there, but there at Penn Presbyterian, part of Penn Medicine, I led the organization as their first chief medical officer. While I was doing that, I was tapped by the governor of Pennsylvania to sit as a chair of the Pennsylvania Patient Safety Authority. That gave me better lenses, better perspective to really sharpen my skills, both in leadership and in understanding patient safety. Now, at The Joint Commission, again, a completely different perspective. It's all come together for me personally.

Sacopulos: Fascinating. I'd like to shift now, talk a little bit about population health. In studying population health, many of us already understood that health disparities in the U.S. certainly exist. But the recent experience of COVID-19 pandemic has exposed the concept of health disparities in a way that is now front-page news. Do you see any encouraging news on this front? Are you aware of any particular initiatives that are encouraging?

McKee: I am encouraged. First of all, disparities in healthcare are one of the most-studied patient safety concerns that we have in this country. More than 50 years of data, more PhDs have been built on this topic. It's a shame that we've done so little. I do think that, with the focus on justice and the pandemic's impact on minority groups, has really helped organizations begin to look at it and accept it as their responsibility as an organization that provides safe care. You can't provide safe care if your women of color died twice at the rate of white women when they're having babies. So, I do think that all of these forces are coming together to help us understand that we've got to use our patient safety and quality improvement infrastructure to address these concerns, and the concerns shouldn't just stay within that infrastructure. They should be part of the mission and the vision of the organization. They should tie up to the strategic plan of the organization as well.

Sacopulos: I agree, this is a known problem. Been very well-studied. Where's been the disconnect between academic knowledge and practical reality, or implementation of things that we know, and we have studied for so long?

McKee: I think privilege plays a role in this, and the bias that we all bring to work. Let's face it. Folks my age were all trained in most likely a segregated healthcare environment. I trained in an organization where the white patients would be treated in one place and the patients of color were in the old building. It's hardwired. We've been talking about disparities, but it's become acceptable. The complacency is not just complacency. "It's not my problem." And what we're trying to get is ownership of this problem. Organizations who do risk contracting are losing financially if they have high disparities in their outcomes. Accountable care, population health, new forms of payment. Give the financial reason why organizations should be focusing on this. It's not just an ethical problem. It is a huge source of financial and societal burden to our society and to our organizations. So, on multiple levels, organizations really need to be looking at this.

Sacopulos: You bring up your medical education, and I'm interested to see what you think is being done with medical education today. Are problems of healthcare disparities and race being taught in a way that you think is effective for medical students and residents?

McKee: I think that there's just the beginning of exploring how to educate and deal with implicit bias, and do bias training with residents, and medical students, and fellows. This is a big experiment. How to do it, no one really knows. Doing nothing, we all know, is wrong. So, we are beginning to see organizations begin to provide this training to residents and enter into a dialogue around race. I really am impressed with the AMA's position that they've recently stated, and the documents that they made, and part of their mission. We do see some of these national organizations owning the problem and moving forward with it.

Sacopulos: That's encouraging. I'd like to shift focus now from physicians and medical education to patients. Let's talk about a topic that I think is on everyone's mind, which is vaccinations. Depending on the report you read, we have a crisis with vaccine hesitancy and trust in medicine, but we also have a situation of difficulty with vaccine access in certain communities. For example, the vaccine may be available, but if you have to take time off of work or get childcare to go get your jab, as the Brits would say, you could risk being fired or have bad effects from that choice. Could you give us your opinion and take on where we are with vaccine hesitancy?

McKee: I think the word vaccine hesitancy, I put it in quotes, because there's also vaccine impediments that are part of the problem. These impediments have been well-identified, and the fact that we haven't been able to create solutions that are reasonable for people who have very restrictive work environments is sort of a shame on us. But I also think that the hesitancy umbrella includes a lot of individuals who are approached in a way where the outcome is intended to be, "No, don't get the vaccine."

In other words, if a physician approaches a patient and says, "I know you folks don't like vaccines, but ..." Well, you have given that person the answer. And we do know that the way the informed consent that is being given, is on the clinician's side. And I do believe that there's a lot of opportunity for improvement to give the person the foundation for making an informed decision. By the way, informed consent is not a problem just with vaccine. It is a problem across all procedural areas in healthcare. But I do think it's the responsibility of the clinician to do the best job they can possibly do to inform the patient properly.

Sacopulos: This sounds like informed consent should not be a one-size-fits-all. Is that correct?

McKee: Exactly. And in some situations, literacy is an issue, so language proficiency is an issue. All of those things need to be taken into consideration as part of the informed consent.

Sacopulos: Is this something that The Joint Commission looks at as part of accreditation?

McKee: We have quite a bit of standards describing patient rights. They're not specific, but one of the kudos I give to The Joint Commission is that in the late '80s they began to, and probably even before that, to delineate patient rights, which didn't exist before. But those rights say, "Yes, I have the right to be informed on all aspects of my care." So, it's not specific to the vaccination, but it applies to all procedural or treatments that a patient's going to get.

Sacopulos: Dr. McKee, our audience today is made up of physicians, physician leaders, and healthcare executives. This is a podcast of the American Association for Physician Leadership, and you certainly are a tremendous leader in the medical community.

From your own leadership journey, could you describe two or three events or opportunities that have shaped you as a physician leader?

McKee: Thank you for that compliment. I like to see myself as a servant leader. I am serving the people I lead, and I lead with that in mind. I think one of the most interesting attributes that a leader needs to have is courage. It's not always easy to stand up for what's right. I've seen great leaders come to that point where they needed the courage, and they stopped short. So, my advice to everybody is, it's not for the fainthearted. There are times when it's easier to retreat than to move forward, and in a thoughtful way, and in a professional way. But I think courage is something that we speak very little of, but it is so important in leadership. The other aspect of what I believe is important to leadership is to build trust with the people that you are leading. That takes some time, and you could ruin it all one day by making a mistake. You got to work on it every day, and do check-ins every now and then, and make sure you're where you are. People tend to work best with those they trust.

Sacopulos: Well said. Can you tell us what's new at The Joint Commission, or any kind of initiatives, or things that the audience may be unaware of that they should be aware of?

McKee: I'm excited about the way we have transformed our dialogue with the organizations from findings to the identification of risk within your organization, and we have some tools to do that. It's called a SAFER Dashboard, where every observation that is identified in an organization is put on this risk matrix to give you a visual of how serious it is and how widespread it is, so that you can actually prioritize and focus your attention based on the level of risk. These dashboards are available for organizations. And now we have them available for health systems, to actually integrate all of their data across all of their organizations and see what patterns and trends they're having across their system, that they can then focus their attention to those.

The other thing that I think is really helpful for us is that we are doing a digital transformation of The Joint Commission. So, we have always been working on the consistency and the accuracy of the survey, so that if we go in Hospital A, we survey it the same way in Hospital B. And now we have tools using artificial intelligence that the surveyors are able to identify something, and not have to rely on their brains and the 600 elements of performance or requirements that we have. But actually, begin to enter it into their computers, and it guides them to the most-likely-accurate place that needs to be cited. That's the way we've been increasing the consistency among our surveyors.

We also are using Power BI, which is a data collection tool that lets us calculate for every surveyor, and there's 500 of them, so there's a lot, how consistent they are and who's an outlier in scoring any particular standard. Someone who doesn't score enough, someone who scores excessively. And we customize the training to that individual using that data analysis. So, we've gotten quite further along in terms of the sophistication of the analysis that we do, and we are still in that transformation. More to come.

Sacopulos: It sounds like you have some very powerful tools to use. I'm interested in the dashboard, if you have found certain types of risk. Maybe something was more or less risky than people had originally thought, but when it was quantified, if there was a surprise. Anything come out and seem odd from that?

McKee: Without this matrix, the penetration is a hole in the wall. And that happens quite frequently in hospitals. Gurneys get bashed in, equipment hits the wall, et cetera. And in our old way we would just say, "You have penetrations in your wall." But the truth of the matter is that that penetration brings different risk depending on where you find it. A penetration, the reason why it's a problem is that it allows fire to go from one area to another. So, it's actually a fire-prevention strategy of eliminating these penetrations. A penetration in the HR department, where everyone is athletic in jobs every morning, is much less riskier than in the intensive care unit, where patients are on ventilators and are in restraints perhaps.

Now, we have the ability to tell the organization, "You have two penetrations here, two holes in the walls. But they are different. You focus first on your ICU issues, and lastly you focus in your HR and your administrative building." That's the way the dialogue has, I think, improved the appreciation that the survey really is a risk assessment. And hopefully, we're giving more and more meaningful information to organization leaders to improve in all of these areas that are identified.

Sacopulos: Certainly, valuable information. Dr. McKee, I could talk to you all afternoon. This is fascinating, but I agreed upfront to keep our time together within certain parameters. And I'm going to honor that, because I know you have lots of important work to do. Thank you so much for joining me on SoundPractice today.

McKee: It was a pleasure.

Sacopulos: It was my pleasure and honor to speak with Dr. Ana Pujols McKee. Many thanks to Dr. McKee for her time and wise thoughts. My thanks also to the American Association for Physician Leadership for making SoundPractice possible. Please join me next time for another new episode of SoundPractice.

https://www.jointcommission.org/about-us/joint-commission-officers/ana-pujols-mckee/

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