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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health I'm your host, Rob Lott. Friends, it's time for another very special episode of A Health Odyssey. As folks know, we typically host the authors of research papers recently published in the pages of Health Affairs. But about once a month, we get to look outside that world and chat with a guest from the broader health policy universe. Today, the very special guest is the incomparable doctor Jonathan Perlin, the president and CEO of the Joint Commission Enterprise.
Rob Lott:For more than seventy years, The Joint Commission has been the leading standard setting and accrediting body in healthcare. Doctor. Perlin has run the organization since 2022. Before that, he served as president for clinical operations and chief medical officer for HCA Healthcare, which as folks know is this enormous health system. He was there during COVID and led the efforts at their literally hundreds of locations focused on preventing and treating the disease at a huge scale.
Rob Lott:Before HCA, doctor Perlin was undersecretary for health in the US Department of Veterans Affairs, where he led the Veterans Health Administration. Again, not exactly a small enterprise. Doctor Perlin maintains faculty appointments at Vanderbilt University and Virginia Commonwealth University. Most importantly, he's published a number of research articles and perspectives in the pages of health affairs over the years, a friend of the organization. And so, you know, here in Chicago, we like to cite our great architects, and it was Daniel Pernham, of course, who advised leaders to make no little plans.
Rob Lott:So Doctor. Perlin has certainly honored that vision during his career in health and healthcare, and I'm really excited to ask him all about it. Doctor. Jonathan Perlin, welcome to A Health Odyssey.
Jonathan Perlin:Well, you, Rob, it's a delight to be with you.
Rob Lott:So let's just dive right in and maybe very briefly we can level set for our listeners. If you ask most health affairs readers what they know about the Joint Commission, I think they'd say that it's the accreditation organization for hospitals and health systems. Is that still a fair description of your core mission?
Jonathan Perlin:Well, Rob, that is really a part of the core. But before we begin in earnest, I want to thank all those individuals who share our vision that all people always experience the safest, highest quality, best value health care across all settings, because that really embraces, encompasses the accreditation that is our central role. We have an administrative responsibility. We serve at the behest of CMS to assure that certain structures and processes are in place to support care. And our mission statement is enabling and affirming the highest standards of health care quality and patient safety for all.
Jonathan Perlin:And our responsibility is upholding the public trust that Care is Safe, that when your mother or mine go into a hospital, that they know that certain quality structures are there and that certain safety practices are in place. But we go above and beyond what CMS requires, and we help organisations address critical issues like medication safety or procedural verification, that if the right patient getting the right procedure and that the surgery is on the right side, that an organisation is prepared for emergency operations, and that we can assure a safe workplace for patients, staff, and visitors alike. But we also have programs that go across the continuum of care, and many are voluntary, But they exist for hospitals, psychiatric hospitals, ambulatory surgery, laboratory, medicine environments. It's mandatory in those environments. And on top of accreditation, we offer a range of certifications that address particular programs.
Jonathan Perlin:Disease specific certifications, cardiovascular, endocrinology, orthopedics, or specialty certifications in other areas like health equity and sustainable healthcare. Rob, I think your listeners may be interested in why Joint Commission is called Joint Commission. And what does that joint mean? Not that.
Rob Lott:You're a bunch of orthopedists,
Jonathan Perlin:It is not. It's, you know, Joint Commission has an extraordinary history. Our predecessor organization was started by Ernest Codman in 1917, in conjunction with the founding of the American College of Surgeons to assure that the technical capacity and equipment for technical surgery and technical medicine was available. And that went along well until World War II. What many may not realise is that physicians ran hospitals up to World War II.
Jonathan Perlin:They of course got drafted off to war, and upon coming back the American College of Surgeons said, we can't do this alone. We need help. And so with the American College of Physicians, the American Medical Association, the American Dental Association, the American Hospital Association, they jointly founded the organisation that we know today as the Joint Commission. And that actually got codified with the Medicare legislation in 1965 that the Joint Commission would serve as a non governmental organisation that extended the capacity of what's now CMS to be able to assure that certain conditions were met for participation in the Medicare, Medicaid and other federal programs.
Rob Lott:Got it, so it's like a team America or sort of an ex men of all the different health care associations tagging tag teaming the accreditation process, is that fair?
Jonathan Perlin:It's really five founding organizations that came together to support the mission of assuring that hospitals and healthcare organizations had the capacity for safe care that got instantiated into public policy the founding of Medicare.
Rob Lott:Okay, so can you give us a sense of the organization's scope and reach today? How many hospitals typically go through your accreditation process? Of those? How many receive the Joint Commission seal of approval? What's that sort of universe look like today?
Jonathan Perlin:Over 80% of US hospitals are accredited through Joint Commission, and only about 1% have an egregious issue that absolutely interrupts the process of moving toward accreditation. Accreditation, though we enhance beyond what CMS requires, is really table stakes for quality and safety. And we have programs that push to go beyond through certification and otherwise. But in addition to The United States, what people may not realize is that we have an international arm known as Joint Commission International, and we do some work in over 80 countries, especially in India, Indonesia, The Far East, The Mideast, Africa, Latin America. And the work tends to be in hospitals that are more sophisticated, lower upper income country and upper middle income countries.
Jonathan Perlin:But one of the things I'm most proud of is a very mission driven program that was launched this year. It's called our Pathways Initiative, and it's really meant for capacity strengthening in lower and middle income countries. It's led by Doctor. Neelam Dhingra, who founded the Patient Safety Unit at the World Health Organization, and the initial work that we're launching is in 15 lower and middle income countries with particularly focused efforts this year in The Maldives, in The Philippines, and Vietnam. So it's a pretty broad scope both domestically and worldwide.
Rob Lott:Yeah, a pretty big reach there. Just going back briefly, some of some of your history, led the Veterans Health Administration, obviously a public sector entity, then many years with with HCA Healthcare, a for profit enterprise. I'm curious what it's been like bringing those experiences to the Joint Commission, which is, not a health system in and of itself and and and it is a not for profit organization. How has that sort of experience been a change for you? I know you've been there about three years.
Rob Lott:And I'm curious how you measure your own success as the leader of an organisation like the Joint Commission.
Jonathan Perlin:Well, me divide that into two parts, as that I feel that my professional life thus far has been a dress rehearsal for the Joint Commission. So I really started in academia. I didn't intend to go into administration, but I kept asking why things didn't work, and found myself more and more involved in quality improvement, and I retread from molecular neurobiology to health services research, ergo the publications and health affairs, thank you for that opportunity. But you know the academic rigor and scientific rigor, coupled with senior governmental experience, coupled with large operational experience across a variety of private settings in The United States, has really imbued me with an understanding of both the public policy, the use of evidence for creating policy, and really the practical aspects, because like me, our new senior leadership team, which is just terrific and comes from senior clinical and operating roles, kind of gets this combination of forces that allows us to both be agile and more effective. This is a tremendously challenging moment in healthcare in all dimensions, and the folks who are part of this team really understand how to help organizations succeed across that variety of challenges.
Jonathan Perlin:I'll just mention a few names, because I'm really proud of the team. Doctor. Jim Maralino came from the Cleveland Clinic, where he was Chief Innovation Officer. He's our Chief Innovation Officer. Doctor.
Jonathan Perlin:Liz Mort is our Chief Medical Officer. She was the Chief Quality Officer for Mass General System and brings extraordinary experiences. I mentioned the Olin Dingre, who started the Patient Safety Unit at the World Health Organization. And Ken Grubbs actually came from my alma mater at HCA, where he had responsibility for regulatory compliance across 2,200 sites of care. And the entire team is really oriented toward wanting to improve the safety and quality of healthcare, but also do so in a way that reduces burden and improves measurable performance.
Jonathan Perlin:And so that means that I have to measure my own success, which I really measure through a demonstration of value by improving health care. And I think our organisation, the Joint Commission, has a history of doing some important things. We've reduced patient harm and improved outcomes measurably. Just last month, I got an email from a friend who's a journalist. He said, I went in for hand surgery and they signed my finger.
Jonathan Perlin:Was that you guys? Yes, the Joint Commission has a policy for secure surgical site verification and that assures that it's the right procedure on the right patient in the right location.
Rob Lott:Now building on all that work, the Commission recently launched, a sort of refresh of the accreditation process. You're calling it Accreditation three sixty colon the new standard. And the top line message that I've taken from some of the articles I've read is that there's a really dramatic reduction in the number of requirements running through that process by about 50% from the number I have here is fifth 1,550 requirements or standards now coming down to seven seventy four standards. Obviously, a big change there. And I'm wondering, you maybe start by saying how how the heck did we reach fifteen fifty steps in the first place, and how are you able to reduce that number without maybe reducing the rigor of the process along the way?
Jonathan Perlin:Yeah, that's a great set of questions, Rob. This is the biggest revamp of the accreditation process, or the elements that are under our control, since Medicare was established in 1965. And let me just break it into four big points. First, I want to start again with a purpose, which is to uphold public trust in the safety of healthcare and provide more effective support for better quality. And as I mentioned, if your family member or mine goes in for care, we should expect that the care is safe.
Jonathan Perlin:But we desire, on top of the expectation for safety, the best possible outcome in managing disease or improving health. So that's really the context for the goal. To the question of why now? There has never been a more brutally complex time in health care, clinically, operationally, financially, even politically. And so we need to increase our focus on what matters most and reduce the burden to already overburdened healthcare organisations and healthcare professionals.
Jonathan Perlin:And so we felt it was imperative to simplify the communications of standards so the expectations are clear. And so for example, there was a standard for recording verbal orders that had 10 separate elements. Those 10 elements have been compressed to one clear statement of expectations. To the question you asked about rigor, it's not less rigorous, it's more focused. And the example I like to use is that running a four minute mile takes way more discipline than walking for thirty minutes.
Jonathan Perlin:And so we want to focus on what matters most. The third point is really the one that we talked about a moment ago, and that is that we're now led by an operationally and clinically experienced leadership team. The folks who are in the senior positions now at the Joint Commission, like me, have all been on the other side of surveys. And they kind of understand what the important pieces are and what's really trivial. And we used a filter to go and reassess the standards.
Jonathan Perlin:And this is the fourth and final point that we called accreditation three sixty because it's a three sixty degree look for strengths as well as concerns. And so in the reduction of those standards, there were a number of features that led us to this dramatic reduction. First, we rewrote the entire standards manual. We separated the CMS conditions of participation from the additional Joint Commission requirements. And by the way, we believe in transparency, so we're posting all the standards publicly this month.
Jonathan Perlin:Second, we're retiring those standards that no longer offer value. The falters we used, are they redundant or obsolete? For example, laws, federal requirements, etc. Mean that smoking no longer occurs in US hospitals. Smoking was in three chapters of the former manual on leadership, environment of care, and life safety.
Jonathan Perlin:And so that meant that we sent likely at hospitals different teams about on journeys to address something that is now obsolete. So that's gone. Standards that weren't evidence based or never cited, they were either a bad standard or just not a problem. Or efforts that were disproportionate to the value of the juice, not worth a squeeze. So those were the filters that we used to retire standards that no longer had value, and I haven't seen a whole lot of tears shed for these standards that we've announced that are gone.
Jonathan Perlin:The third is that we've enhanced the survey report itself. No longer are we providing feedback through cryptic codes, but instead we've replaced that with natural language, particularly on something we call the SAFR matrix, which actually plots the severity of an issue versus the prevalence of an issue. And rather than having these IC and EC and MS codes on there, we just have the natural language of what the issue was. And when there are a list of issues where there might be a citation or requirement for improvement, they're listed by priority, not randomly. Fourth, we've introduced some, I think, very useful benchmarking tools.
Jonathan Perlin:We've been sitting on fifty years of data that we haven't used, and now an organisation can look in a particular domain or compare in a system, one hospital to another, or identify benchmarks that are similar organisations. Next, we have introduced the SAFEST program. This is an acronym for the survey analysis for evaluating strengths, looking for leading practices, and we're building a video library of top sighted performance opportunities. Next, there's an optional continuous support program. So we don't want organizations studying for a test.
Jonathan Perlin:You want your doctor, you want your nurse, you want your pharmacist, you want your hospital to be test ready all the time. And that's our goal. It's not a gotcha. It's really meant to give organisations, health workers, the tools to be as successful as possible. And finally, it's really about surveyor excellence.
Jonathan Perlin:The new cadre of surveyors, of which there are over a thousand, are typically mid career individuals, leaders who teach and enjoy learning, who want to travel and see other approaches. They appreciate the accountability aspect to upholding the public trust, but they're committed to improvement. So they go with an educational imperative and an intent to be collaborative. And so in summary, goal is really better outcomes while reducing burden and better tools and support for hardworking caregivers.
Rob Lott:Wow, a lot to process there. I wanna ask you a little more about how all of those changes might translate into, better care at the end of the day. But first, let's take a quick break. And we're back. I'm here with doctor Jonathan Perlin, president and CEO of the Joint Commission.
Rob Lott:We're talking about or we recently heard about the, really massive changes they've undertaken to the accreditation process. And I guess I wanted to ask you about, I think there's a temptation to dismiss accreditation as sort of an administrative burden, a necessary one at that, but, burden nonetheless for a lot of hospitals and health systems. And I'm wondering, I'm gonna give you a kind of a softball here, but I'm gonna ask you to resist the temptation to to knock it out of the park, instead maybe try to put some some spin on it and get an infield hit here. Can you give me a sort of sunnier version of the accreditation story beyond something that just hospitals are required to go through and is instead maybe an experience that is integral to their broader mission?
Jonathan Perlin:Well, you know, it's a fair question. And I hope the work we're doing with Accreditation three sixty helps to change the survey from being perceived sometimes as a regulatory hurdle to really a component of a comprehensive data driven quality improvement program. And with that, I want to get back to first principles. And since you just gave a baseball metaphor, I want to quote the great philosopher Yogi Berra, who said famously, You can observe a lot just by watching.
Rob Lott:Fair enough.
Jonathan Perlin:A confession: I came to Joint Commission with some skepticism about surveys. I wondered if we couldn't actually do better just with data. Observing a lot just by watching happened to me in the process of observing surveys. And so I want to tell you a story about what I observed at a mid size, say 300 to 400 bed hospital, part as of a mid size 30 to 70 hospital system in an average suburb of a large American city. And so we're walking around, and between two ORs, there's a steam steriliser autoclave.
Jonathan Perlin:And the infection control nurse asks, what's that fair for? So, well, that's for flash sterilizing instruments. Flash sterilizing is used when you don't have something, you need it immediately. It's not ideal because the instruments come out wet and they're not scrubbed in the same way or packaged in the same way. So it's a riskier approach, though decent.
Jonathan Perlin:And so the nurses say, must be used pretty infrequently. Oh no, we use it for every case. Why? Because the doctors like their particular instruments. How do you program it?
Jonathan Perlin:We use these instructions on top. There's one of those plastic folded display frames, and it clearly says instructions are, for example only, not to be used for programming, and at the bottom it says downloaded by Google, and it was like, oh gosh, this isn't good. And then we walked to the sterile pharmacy and put on our sterile suits. On one side everything's by the book. On the other side, pharmacist or pharmacy tech is not making the medication that's going to be injected under the hood, but is changing pipette tips and, you know, sucking up the solvent outside of the hood.
Jonathan Perlin:May as well make it on the kitchen counter. There was a systematic problem with infection prevention in this organization. Now, maybe something bad hadn't happened yet. But remember, there was this terrible episode in 2012 where a compounding pharmacy in Tennessee created these steroids for epidural injection. They likely got away with bad, inappropriate technique for a period of time.
Jonathan Perlin:But ultimately, I remember this, there were thirteen thousand exposures, there were roughly seven fifty cases, there were sixty three deaths across 20 states. And so the survey helps uncover latent risk, and latent risk is a hidden or underlying condition or a system flaw that has the potential to cause harm but hasn't yet resulted in adverse events. And so we have a big challenge, and that's that it's incredibly difficult to measure bad things that don't happen from uncovering latent risk. And so the goal is obviously to prevent manifest harm or actual injury. But that's why boots on the ground and direct observation is critical.
Jonathan Perlin:I believe at this facility we uncover latent risk. And by helping them change their practices prevented actual harm. It's just difficult to measure that.
Rob Lott:I know we have limited time with you, and I'd like to touch on a bunch of topics fairly quickly. So I thought we could maybe do a little bit of a lightning round. We've never done this on the podcast before, but this seems like a a great opportunity. I wanna mention a number of sort of urgent topics in health care today, and I'd like you to tell me maybe one thing, just perhaps a sentence or two where you're perhaps feeling optimistic about that topic, and then we'll go to the other side and ask you to maybe reflect on something that is leaving you a little, I was going to say worried, but let's say uncertain about sort of the future prospects in this area. And we'll try to keep it short and quick for each of these.
Rob Lott:Are you game to give this a shot?
Jonathan Perlin:Let's play ball. All right. Okay, topic number one, telehealth. Positive, really not new. Its use and utility was demonstrated during COVID.
Jonathan Perlin:It's a great way to augment care, especially in areas like behavioural health or supporting mobility impaired or transportation limited patients or frail elders. Concern should provide the same quality as in person care. And by the way, we offer a telehealth certification to assess that.
Rob Lott:Great. Yeah, lots of good research in the pages of Health Affairs as well, a little plug there into sort of looking at comparing the quality of care telehealth versus in person. So glad that that's on your radar as well. All right, topic number two, artificial intelligence.
Jonathan Perlin:Positive. This is the defining technology of the century, changes everything. It offers a step change, an economic term which means discontinuous improvement, in quality and safety, especially things like diagnostic accuracy. Andy Auerbach at UCSF published a paper recently that showed that twenty three percent of patients who die or deteriorate in American hospitals do so because of a missed or a misdiagnosis. AI has tremendous opportunity to improve that.
Jonathan Perlin:Concern? That there are appropriate guardrails to prevent unintended consequences, harm. For example, chemotherapy recommendations for children that are based on an adult population. This is why we are building a responsible use of AI certification. We want the benefits, but we want the appropriate guardrails, and, we want to facilitate the innovation, because there's so much opportunity.
Rob Lott:Okay, next topic, vaccines.
Jonathan Perlin:Okay, the positive. Things like Project Warf Speed demonstrated the capacity of mRNA vaccines in meeting new epidemic or pandemic threats. The concerns. Joint Commission introduced a healthcare worker flu vaccination requirement a number of years ago, and patient deaths in the newborn intensive care unit and bone marrow transplant units from identical strains as the caregivers went down. I worry about vaccine hesitancy.
Rob Lott:Fair enough. Climate change.
Jonathan Perlin:Sustainability in health care is critical for both public health and operating efficiencies. And in fact, younger health care workers and clinicians, according to the Commonwealth Fund, think they and their organizations should do more in terms of sustainable health care. Healthcare organizations are 5% of commercial force space but represent 10% of energy consumption, and hospitals are three quarters of that 10%. And so given the cost pressures, healthcare organisations can't afford not to hedge their energy costs. And again, Joint Commission offers a sustainable healthcare certification to help in organizing that work.
Rob Lott:Next one, opioids.
Jonathan Perlin:Okay, I'm going to start with a concern first here. Our country has been through the wringer. But a key issue is admitted in the conversation. Fundamentally, we need better pain medications. And the positive here is that AI and synthetic biology are helping us find new pathways for pain medications that are stronger than nonsteroidals but don't have the addictive properties of opiates.
Rob Lott:And last but not least, diagnostics.
Jonathan Perlin:Oh, well, know, are two pieces here. AI will improve diagnostic accuracy, as I mentioned. But we're entering an era where things like the liquid biopsy, essentially a blood test that says you have cancer, may not say what cancer could potentially, this is the concern, generate a number of false positives that would drive a lot of suffering and unnecessary and potential harmful testing and even procedures.
Rob Lott:All right. Well done. Nice work on the lightning round. I appreciate your playing ball here. We're almost out of time.
Rob Lott:I did wanna perhaps wrap up with an opportunity to sort of reflect. And I know it's been about twenty five years since the landmark paper to is human was published reflecting on and sort of reporting significant gaps in terms of patient safety and healthcare quality. If we were to pick a random hospital patient in a random hospital in America, how do you think their experience might be different today than it was twenty five years ago? How might it be the same? And how is that transition informing your work at the Joint Commission?
Jonathan Perlin:Yeah, it's a great question. And I can't start to address that question without just acknowledging that we lost one of the pioneers in patient safety this past month, Doctor. Lucian Leap, who really helped define that preventable harm wasn't just a bad outcome, but something that we really need to think scientifically about and take responsibility for. So let me start with the progress over the past twenty five years, then come to what that patient might see in a typical hospital. And I think it's important to recognise that there's been tremendous progress over the last two and a half, three decades.
Jonathan Perlin:First, we have a vocabulary for quality and safety. We have an understanding of the difference between bad outcomes that may not be preventable and preventable harm. And consistent with that, we have a philosophy that preventable harm isn't just bad luck. There are some papers, there are some who will say, well, gosh, the rates of error are unchanged. I'd offer that that's not entirely accurate.
Jonathan Perlin:There's a fair question, which is why haven't we made more progress? But let's go back to this issue that says, well, things haven't changed. Well, health care has changed. So the substrate in which failure is being measured has changed immensely. Healthcare is far more complex and offers far more in terms of opportunity than it did three decades ago.
Jonathan Perlin:Scientifically, clinically, operationally, financially, socially, politically, healthcare is tremendously different than when terrorist human came out. Let's look at the clinical opportunities. HIV was a death sentence. Today, it's a manageable chronic disease. Heart failure is no longer an inevitable consequence of a major heart attack.
Jonathan Perlin:That heart attack can be interrupted and heart failure may never occur. And if it does occur, are drugs like ACE inhibitors that can allow heart failure to be treated, to be managed. Twenty five years ago, cancers were named by the site where they were detected. Today, that's far less relevant than the molecular biology of the cancer, which gives us a key to unlock doors, not just to managing, but oftentimes cure. And so it's a very different environment.
Jonathan Perlin:I think the big challenge that we have is that we keep using the same tools to look for failure modes. We keep assuming that if we just record why something failed, it'll generalize to all their circumstances of failure. And the classic example is that we remove bottles of potentially lethal injectable potassium from lookalike bottles of IV flush sodium chloride saline. I wish everything were like that. But it's not like that.
Jonathan Perlin:Nor is health care interchangeable with aviation. Aviation is a relatively closed system, and it has a set of identicalities that are very different from healthcare. One plane of a particular model is identical to others of the same model. And if you use that aviation metaphor and take it even further, the destinations for patients aren't necessarily known beforehand. My flight from Baltimore to Boston wasn't going to end up in Burbank or Biloxi or Birmingham.
Jonathan Perlin:A patient who presents with chest pain could be going to heart attack or gastritis or dissecting aneurysm or pneumonia, among any number of other destinations. There's an Australian Health Services researcher, Doctor. Braithwaite, Geoffrey Braithwaite, who's I think really helped us by introducing a concept of Safety two point zero, which is really coupling looking for failure modes, and Safety two point zero looking at success modes in complex adaptive systems, and trying to understand why things work. And this is really part of why we're introducing our safest program, to identify strengths, to understand how in systems that adapt in real time success can be achieved. And so I think that the opportunity, the real opportunity, is understanding both failure modes, that safety one point zero, and coupling it with success modes, safety two point zero, to create safety three point zero.
Jonathan Perlin:So let me come back to what does that patient in a hospital experience? Well, today, compared to twenty five years ago, they experience electronic health records that ensure their past medical history is there, that their allergies are known. They experience that closed loop of medication administration to assure that they get the right drug and the right dose by the right route at the right time. They get that nurse and physician who sign lateral sites to make sure that the correct kidney, knee, finger, eye receive surgery. They get an organisation that doesn't just review catastrophe, but an organisation that has a systematic approach to understanding close calls.
Jonathan Perlin:They get a community that taps into safety science, and most importantly, they get a better chance for improving health or curing disease. And that's what makes this job so exciting, as we get to be at the centre of helping advance that safety science.
Rob Lott:Wow, a really optimistic view of the last twenty five years and of hopefully the years to come. So Doctor. Perlin, thanks so much for taking the time to chat with us today, I had a great time.
Jonathan Perlin:Well Rob, thank you for the privilege of participating on the Podyssey, and thanks for the important health reporting you and health fairs do, and thanks to all who are advancing healthcare.
Rob Lott:For sure, and to our listeners, thanks again for tuning in. If you enjoyed this episode, please tell a friend, leave a review, and, of course, tune in next week. Thanks, everyone. Episode, I hope you'll tell a friend about a health podcast.