The Joint Commission health care equity standard will become a National Patient Safety Goal effective July 1, 2023. So, why the change from standard to National Patient Safety Goal?

Clearly, TJC is emphasizing the importance of health care equity as a quality and safety priority. Hence, they’re elevating it to the level of a National Patient Safety Goal. That designation means it should be a top priority for accredited organizations.

Health Care Equity NPSG: Which Accreditation Programs?

The new health care equity National Patient Safety Goal 16 applies to both hospitals and behavioral health organizations. Specifically, it applies to those behavioral health organizations that provide the following services:

• Addictions services
• Eating disorders treatment
• Intellectual disabilities/developmental delays services
• Mental health services
• Primary physical health care

Joint Commission Health Care Equity Requirements

The health care equity requirements will move from the Leadership chapter to the 2023 National Patient Safety Goals. There are no content changes to the requirements. In short, organizations must do the following:

• Identify an individual to lead activities to improve health care equity.
• Assess patients’ health related social needs.
• Analyze quality and safety data to identify disparities.
• Develop an action plan to improve health care equity.
• Act when the organization does not meet the goals in its action plan.
• Inform key stakeholders about progress to improve health care equity.

For more details on how to manage this important initiative, see our earlier post Joint Commission Health Care Equity Requirements.

Health Care Equity Resources

Many clients ask where to find resources that are relevant to their organization. First, we recommend you review TJC’s R3 Report 36 New Requirements to Reduce Health Care Disparities. It provides the rationale for each of the requirements as well as a host of excellent reference publications.

Next, check out the many health care equity resources available from the Substance Abuse and Mental Health Services Administration. SAMHSA has its own Office of Behavioral Health Equity. This Office coordinates SAMHSA’s efforts to reduce disparities in mental and substance use disorders across populations.

Also, take a look at the 15 Important Steps for Creating Behavioral Health Equity from Comprehensive Alcohol and Substance Abuse Treatment (CASAT.) These steps provide a solid foundation for building your health care equity initiative.

In addition, TJC’s Health Care Equity Resource Center is up and running and has some excellent resources. Check it out.

Implications for Your Joint Commission Survey

You can anticipate surveyors will explore the topic of health care equity during your Leadership Session and perhaps your Data Use Session as well. Here’s some questions surveyors have asked on recent surveys:

• Who’s leading the health care equity initiative in this organization?
• What data have you collected so far on your patients’ health related social needs?
• Have you identified any health care disparities in your patient population?
• Where are you at with developing an action plan to address at least one of these health care disparities?

Also, keep in mind you’re required to inform your key stakeholders about your health care equity initiatives. So, you’ll want to be able to show how you’ve communicated with your governing body, licensed practitioners, and staff about your work in this area.

Barrins & Associates Consultation

We’ve incorporated these new Joint Commission health care equity requirements into our Mock Surveys and Continuous Readiness Consultations. As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.