Quality Measures

Hospital operational changes underway as health equity becomes one of The Joint Commission’s National Patient Safety Goals

The designation means hospitals can expect health equity to become a stronger focus of accreditation surveys.

April 10, 2023 11:48 am

Reducing healthcare disparities became a Joint Commission accreditation standard (LD.04.03.08) on Jan. 1, a little more than a year after the organization issued a Sentinel Event Alert warning of impacts on patient safety. However, on July 1, the standard will become a National Patient Safety Goal (NPSG), which experts say points to one thing: Healthcare organizations must have a plan in place to promote health equity.  

“When The Joint Commission adopts a standard as a National Patient Safety Goal, it gets an added layer of attention as part of the triennial survey that hospitals undergo [to receive accreditation],” said Akin Demehin, director of policy at the American Hospital Association (AHA). “Hospitals should take this as a signal that health equity is a priority and that The Joint Commission will ask them to demonstrate compliance.”

Jen Cowel, president of Patton Healthcare Consulting, agrees. “This is a huge priority for our country,” she said. “The Joint Commission wants to know whether it’s a priority for your organization, too — that your C-suite is involved in formulating a plan.”

Be prepared to talk at length about health equity efforts in your organization, Demehin said.

“What I’ve heard is that conversations with The Joint Commission have been very robust as surveyors seek to understand the work hospitals are doing in this space,” he added.

How hospitals should adapt

Although the standard soon will become an NPSG, the intent of the requirements has not changed, said Kathryn Petrovic, director, Department of Standards and Survey Methods at The Joint Commission.

“We elevated the healthcare equity accreditation requirements to a National Patient Safety Goal to strengthen the link between healthcare equity as a quality and safety priority,” she said.

Experts say The Joint Commission may ask these questions during hospital accreditation surveys:

  1. Have you appointed a designated leader of health equity?
  2. Do you assess health-related social needs?
  3. Do you provide patients with community resources and support services?
  4. Do you stratify data to identify healthcare disparities?
  5. Have you created a written action plan to address disparities?
  6. Have you reduced disparities, and do you monitor and report progress?

Hospital operations and workflows may change now that health equity is becoming an NPSG, said Cowel.

“We will see a lot of creative ways to address this,” she added.

Possible initiatives include bringing mobile clinics to specific communities to overcome transportation barriers. Another example: Organizing a farmer’s market on hospital grounds to address food deserts.

Strategic approaches are key

Cowel encourages organizations to think about health equity as a data-driven quality improvement project and, in turn, to approach it using a specific performance improvement model such as the Plan, Do, Check, Act cycle.

A key point is that organizations seeking to maintain accreditation have the flexibility to assess social needs for all patients or only a representative sample, Cowel noted. The same is true for the sociodemographic characteristics they use for data stratification — they can use one characteristic or many.

“Don’t be overly ambitious,” she said. “It’s better to zero in on and improve one disparity rather than tackle multiple issues.”

For example, many organizations already have begun to address disparities in maternal mortality in the wake of new data from the Centers for Disease Control & Prevention. The data show a 38% increase in the maternal mortality rate between 2020 and 2021 as racial disparities in outcomes continued to widen.

Some providers already may have identified and targeted a specific population based on their participation in the Merit-based Incentive Payment System (MIPS), Demehin said. MIPS inpatient quality measure #487 (screening for social drivers of health) requires organizations to track the percentage of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety.

However, in addition to checking the boxes of the standard, The Joint Commission will want to see that health equity is weaved throughout an organization, said Mark Howell, AHA’s director of policy and patient safety.

“It’s something that should be ingrained in the culture of the organization,” he said. “How are you going to successfully implement and coordinate your action plan throughout your entire organization? It will need to touch on workforce, community work and care delivery. It’s a very broad issue that requires a great deal of attention and focus.”

Said Demehin, “Just as with advancing patient safety, advancing health equity really requires the involvement of the entire organization. It’s not just one person who will make it happen. The whole organization must come together, commit to goals and make progress. It’s a continual process of assessment, reassessment and improvement.”

Resources for hospitals


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