The new Joint Commission health care equity requirements go into effect January 1, 2023. This promises to be a major Joint Commission focus area.
Rightfully so, since research shows disparities in access to health care and disparities in quality of care persist in our country. Accordingly, TJC has identified health care equity as a quality and safety priority.
So, let’s review the key requirements and how to get started in your organization. These new requirements are applicable to both the Hospital and the Behavioral Health Care and Human Services accreditation programs.
New Leadership Standard on Health Care Equity
First, there’s a new standard on health care equity in the Leadership chapter: LD.04.03.08. It’s essentially the same in both the Hospital and Behavioral Health Care standards.
Hospital Standards: Reducing health care disparities for the hospital’s patients is a quality and safety priority.
Behavioral Health Care Standards: Reducing health care disparities for the individuals served by the organization is a quality and safety priority.
Joint Commission Health Care Equity Requirements
Specifically, there are six requirements your organization must meet as listed in the Elements of Performance for this standard:
# 1: A Designated Leader
You must identify a leader responsible for activities to reduce health care disparities within your organization. Clearly, TJC is looking for a high level leader to head up this initiative. In addition, the C-suite and the Board should be involved.
# 2: Health-Related Social Needs
This EP actually has two requirements. First, you must assess the patient’s health-related social needs (HRSNs.) Second, you must provide information about community resources and support services to help address those needs.
For example, HRSNs can include:
- Access to transportation
- Difficulty paying for prescriptions or medical bills
- Education and literacy
- Food insecurity
- Housing insecurity
Your organization has the flexibility to determine which patients to assess for HRSNs; which HRSNs to assess; and which resources to provide to address HRSNs. Also, you can focus either on a representative sample of patients or collect data from all patients.
# 3: Stratification of Quality/Safety Data
You must identify health care disparities in your patient population by stratifying your quality and safety data using socio-demographic characteristics. Examples of socio-demographic characteristics include age, gender, preferred language and race/ethnicity.
The goal here is to understand which patient care processes and outcomes vary by socio-demographic characteristics. Again, you have the flexibility to choose which measures to stratify and which socio-demographic characteristics to use for stratification.
Also, you can focus on measures that affect all patients such as their experience of care. Or, you can focus on a subset of your patient population such as substance use disorders.
# 4: Action Plan
You must develop a written action plan describing how you’ll address at least one of the health care disparities you identified. TJC recognizes this can be a challenging initiative. Thus, they require you to address only one topic of disparity even if you identify multiple disparities.
Your action plan should include the following components:
- Identification of the health care disparity
- The specific population of focus
- Statement of your improvement goal
- Strategies and resources needed to achieve the goal
- Process you’ll use to monitor and report progress
# 5 Make Improvements
At this stage, you implement your action plan. You should also monitor your progress and evaluate your success in reducing the health care disparity. Moreover, you must take action when you don’t meet the goals specified in your action plan.
# 6: Stakeholders
You must inform your key stakeholders at least annually about your progress to reduce health care disparities. This includes leadership, governing body, licensed practitioners, and staff. You can do this through a variety of forums such as quality meetings, town halls, newsletters, and your intranet.
Key Takeaways and Next Steps
A key point to keep in mind is that this is a data-driven, quality improvement initiative. Hence, it should be organized as a formal QI project and have robust data analysis resources.
TJC is well aware this will be a new endeavor for many organizations. Accordingly, they’re allowing flexibility in the implementation of these new requirements.
At the same time, they’ll expect to see you’ve begun initial implementation of the key components. So, here’s our recommendations for next steps:
First, identify an executive leader to lead this initiative organization-wide as well as a formal QI Project Team. Be sure to include your Data Gurus since there’s a strong focus on data collection and stratification.
Next, review TJC’s guiding documents on the new requirements:
Prepublication Requirements Related to Reducing Health Care Disparities: Hospital Accreditation Program
Prepublication Requirements Related to Reducing Health Care Disparities: Behavioral Health Care and Human Services Accreditation Program
R3 Report Issue 36: New Requirements to Reduce Health Care Disparities
Sentinel Event Alert Issue 64: Addressing Health Care Disparities by Improving Quality and Safety
Then, begin your data collection and analysis to determine where you’ll focus your quality improvement initiative to improve one of your health care disparities. Use your PI model (such as Plan, Do, Check, Act) as the organizing framework for the project.
Measure and evaluate your progress throughout the project. Be sure to incorporate this initiative into your organization wide QAPI program.
Throughout the project, issue progress reports to leadership, governing body, medical staff, managers, and staff throughout your organization.
Barrins & Associates Consultation
We’re incorporating 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.