New Joint Commission Standards to Reduce Healthcare Disparities – What You Need to Know

This blog is taken from a recent HealthStream webinar entitled “New Joint Commission Standards Aim to Reduce Healthcare Disparities: 6 Things Your Organization Should Do Now.” The webinar featured Kathy Poston and Shaifali Ray. Both presenters are Vice Presidents, Client Delivery for Chartis Just Health Collective.

The health care industry continues to develop strategies that will address health disparities. National organizations are committing those health equity strategies into regulations and standards. Beginning in 2023, The Joint Commission will be incorporating health equity into its accreditation standards. These new standards will apply to accredited ambulatory, behavioral health and human services organizations, critical access hospitals, and acute care hospitals and will aim to reduce healthcare disparities.

This briefing focused on these new standards. HealthStream partner, Chartis Just Health Collective, shared considerations beyond “check the box” strategies and focused on tactical actions health care organizations can take right now to meet these new standards.

What Is Health Equity?

Poston began by defining health equity in terms of what it is and is not. “Health equity is a transformation of the organization’s culture, strategy and operations to create a healthcare system that is free of bias, discrimination and health care disparities,” said Poston. She encouraged leaders not to think of health equity as simply a department, training program, educational program, checkbox activity, project or methodology. 

The Joint Commission is bringing this issue into even sharper focus for hospitals by developing accreditation standards for leadership, patient rights and medical records. However, the Joint Commission is not the only agency that has developed health equity standards for healthcare organizations. Ray identified some additional agencies and accrediting bodies that will be focusing their attention on this issue.

• The Centers for Medicare and Medicaid Services (CMS) has adopted new health equity quality measures as part of their quality reporting program.
• The National Committee for Quality Assurance (NCQA) has also established a framework to address equity and require culturally and linguistically-appropriate services for patients and employees.
• The Accreditation Council for Graduate Medical Education (ACGME) had developed a framework for continuous learning to address diversity, equity and inclusion in graduate medical education.
• Individual states have also introduced statutes and legislation aimed at improving access and addressing disparities in healthcare.

The Joint Commission Health Equity Focus Areas

As health equity becomes more of a focus for regulators and accrediting bodies, the Joint Commission has identified three focus areas. Ray shared that these standards became effective in January and they focus on three areas:

• Leadership: This standard ties the most directly to identifying and reducing disparities and includes six elements ranging from the identification of a leader for improving health equity, collecting and analyzing data to identify disparities to developing action plans to address shortcomings that are identified. Ray shared that this standard will be elevated to National Patient Safety Goal 16 effective July 1, 2023.
• Rights and Responsibilities of the Individual – This standard focuses on a patient’s right to respect and prohibits discrimination for any reason.
• Record of Care, Treatment and Services: This standard requires that the medical record include the patient’s race and ethnicity.

Six Steps to Take Now to Prepare for the New Joint Commission Standards

Ray and Poston then turned their attention to steps that hospital leaders should take today to prepare for these new standards.

1. Designate a leader to reduce disparities. Healthcare organizations will be focused on and responsible for activities resulting in the reduction of disparities and improved health equity. Poston emphasized that it is critical that this leader be supported with both staffing and financial resources as well as being impowered to make decisions to support the initiative.
2. Prioritize medical staff training for accurate data collection. Racial data collection that is consistently and reliably collected will become required as part of the new standard. Start now to ensure that staff are comfortable collecting the data and that they can do so reliably and accurately.
3. Ensure data reflects patient’s care, services and treatment. Poston and Ray recommended standardizing data collection of demographic data beyond race and ethnicity and that it be done across the organization or system.
4. Leverage multi-disciplinary teams for reporting and performance improvement. Convene teams that will include representatives from such disciplines as quality, safety, clinical operations and others to develop multi-disciplinary action plans.
5. Regularly assess and incentivize to ensure that goals are being met. Leaders should also design incentive and accountability programs to ensure that team members are focused on the data and the goals.
6. Inform key stake holders about progress. Report progress to internal and external stakeholders on at least an annual basis.