Updates on Health Equity Measures: The Joint Commission

Learn more about the health equity elements from The Joint Commission

June 14, 2023
Learn more about the health equity elements from The Joint Commission

In recent years, addressing health equity has become an increasingly important priority for governing and accrediting organizations within the healthcare sector. These organizations recognize the urgent need to ensure that every individual, regardless of their background or socioeconomic status, has equal access to quality healthcare services. To achieve this goal, various measures have been put forth by these governing and accrediting bodies, aiming to eliminate disparities in outcomes and improve the overall health and well-being of all populations. Late last year, we explained the 5 domains of CMS’s new health equity measure. Now, we summarize the new standard put out by The Joint Commission that has 6 elements of performance.

Effective January 1, 2023, The Joint Commission (TJC) issued a new standard, LD.04.03.08, in the Leadership (LD) chapter with 6 new elements of performance designed to address healthcare disparities as a quality and safety priority. TJC is a nonprofit who accredits over 20,000 healthcare organizations and programs in the country. Organizations undergo onsite surveys every 3 years to maintain accreditation. To qualify for Medicaid or Medicare reimbursement, most states require organizations to be accredited.  

The requirements of Standard LD.04.03.08:

EP 1: The organization designates an individual to lead activities to reduce healthcare disparities for the organization’s patients.

Our take: This designated leader is responsible for developing and implementing strategies to address disparities in healthcare access, outcomes and quality of care. They should work closely with providers, administrators and community organizations to identify barriers to equitable care and develop initiatives to overcome them. This includes seeking the best resources such as technology to identify ways to identify and help underserved patients, promoting cultural competency training for healthcare professionals, implementing language services to improve communication with diverse populations, and establishing partnerships with community-based organizations to better understand and meet the specific needs of underserved communities.  

EP 2: The organization assesses the patient’s health-related social needs and provides information about community resources and support services (examples include transportation, difficulty paying for prescriptions or medical bills, education/literary, food insecurity, housing insecurity).

Our take: Healthcare organizations have recognized that addressing social determinants of health is crucial in promoting equitable healthcare access and outcomes. As part of this measure, when patients seek care, providers or care coordinators conduct screenings or assessments to identify social needs that may impact their health. These screenings may include identifying transportation challenges, difficulties in paying for prescriptions or medical bills, educational or literacy needs, food insecurity or housing insecurity.

Once the needs are identified, healthcare organizations provide patients with information about community resources and support services available to address those needs. This may involve utilizing technology to identify assistance programs to fund these services, providing financial counseling services, and finding resources such as community health clinics, food banks, affordable housing programs to help these patient populations. By addressing the social determinants of health and connecting patients with appropriate resources, healthcare organizations aim to improve patients' overall well-being and reduce healthcare disparities rooted in social inequities.

EP 3: The organization identifies healthcare disparities in its patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients (organizations may focus on areas with known disparities in the scientific literature (e.g., diabetes, kidney disease, substance disorder, etc.).

Our take: Healthcare organizations need to be able to understand and address disparities in outcomes among different patient groups. To achieve this, they analyze quality and safety data, such as clinical outcomes, patient satisfaction and healthcare utilization rates, while considering sociodemographic factors such as race, ethnicity, income, education level and geographic location. By stratifying the data based on sociodemographic characteristics, organizations can identify disparities that exist within specific patient populations. For instance, they may find that certain groups disproportionately experience disparities in the management of chronic conditions like diabetes, kidney disease or substance use disorders. This evidence-based approach allows organizations to target areas of known disparities and allocate resources and interventions accordingly.

Once healthcare disparities are identified, organizations can implement targeted strategies and interventions to reduce those disparities. This may involve utilizing technology to intervene early in providing assistance, implementing culturally sensitive care practices, increasing access to preventive services, and providing targeted health education and outreach programs.  

EP 4: The organization develops a written action plan that describes how it will address at least one of the healthcare disparities identified in its patient population.

Our take: Once disparities are identified through data analysis and stratification, healthcare organizations understand the importance of taking concrete steps to address and mitigate those disparities. The written action plan serves as a roadmap that outlines specific strategies, goals and interventions aimed at reducing the identified healthcare disparities. For example, if the analysis reveals disparities in access to preventive services among certain patient groups, the action plan may include initiatives such as increasing outreach efforts, intervening early to find assistance programs, implementing culturally tailored education campaigns and improving the availability and affordability of preventive screenings or vaccinations.

By developing a comprehensive action plan, organizations demonstrate their commitment to addressing healthcare disparities and provide a framework for systematic and targeted interventions. This approach helps organizations prioritize and allocate resources effectively, track progress and hold themselves accountable for achieving equitable healthcare outcomes for all patient populations.

EP 5: The organization acts when it does not achieve or sustain the goal(s) in its action plan to reduce healthcare disparities

Our take: Recognizing that progress may not always be immediate or linear, organizations understand the importance of continuously monitoring and evaluating the effectiveness of their initiatives. In cases where the desired goals are not met or sustained, the organization should take proactive steps to reassess and adjust its strategies. For instance, if the action plan aimed to reduce disparities in access to mental health services but did not achieve the expected results, the organization may engage in a thorough review of the implemented interventions. They should seek input from staff, patients and community stakeholders to gain insights into the barriers faced by the target population and identify gaps in the provided services.

Based on the findings of the assessment, the organization can modify its action plan by refining existing strategies, introducing new interventions or technology, and/or reallocating resources to address the identified challenges. By acting upon the shortcomings in achieving their goals, organizations demonstrate their commitment to addressing healthcare disparities and their willingness to adapt and improve their efforts. This iterative process allows them to learn from their experiences, make necessary adjustments and continuously strive towards achieving equitable healthcare outcomes for all patients.

EP 6: At least annually, the organization informs key stakeholders, including leaders, licensed practitioners and staff about its progress to reduce identified healthcare disparities.

Our take: Because of the importance of transparency and accountability, organizations ensure that their efforts to address disparities are communicated to relevant individuals within the healthcare setting. Regular meetings should be held where leaders, licensed practitioners and staff are informed about the progress made in reducing healthcare disparities. This should include sharing data on key performance indicators, outcomes and measurable improvements achieved over the past year.

For instance, the organization might present information on the percentage reduction in disparities in specific healthcare outcomes, improvements in patient satisfaction ratings among underserved populations or increased utilization of preventive services in disadvantaged communities. These updates provide stakeholders with a clear understanding of the organization's efforts and the impact it is making towards achieving health equity. Additionally, these updates serve as an opportunity to engage stakeholders in discussions and solicit their input. It allows for the sharing of best practices, lessons learned and innovative ideas that can further enhance the organization's strategies in addressing disparities.  

By regularly informing key stakeholders about progress, organizations foster a culture of transparency, collaboration, and shared responsibility in their efforts to reduce healthcare disparities. This approach promotes a collective commitment to achieving health equity and ensures that all relevant parties are aware of the organization's ongoing efforts and advancements.  

Additionally, TJC also made addressing healthcare disparities a new National Patient Safety Goal 16.01.01.

To learn more about these health equity measures and the various strategies that can be implemented, download our white paper.