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The Journey to Achieve Health Care Equity: The New Joint Commission Accreditation Standard and Call for Papers

Published:August 28, 2022DOI:https://doi.org/10.1016/j.jcjq.2022.08.009
      Almost 20 years ago, the Institute of Medicine (now the National Academy of Medicine) published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The report reviewed the voluminous literature on differences in quality of care and use of services by racial and ethnic minorities and concluded: “A large body of published research reveals that racial and ethnic minorities experience a lower quality of health services, and are less likely to receive even routine medical procedures than are white Americans.”
      • Medicine Institute of
      Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
      (p. 2) Although racial and ethnic differences in care have received the most attention, studies have also shown disparities in care for women, older adults, people with disabilities, and other historically marginalized groups.
      Health care disparities are often viewed through the lens of social injustice. Yet, at the most basic level, disparities are a quality of care problem similar to many others. Like medication errors, health care–acquired infections, and falls, health care disparities must be examined, the root causes understood, and the causes addressed with targeted interventions. There are many examples of efforts that took this approach and successfully reduced disparities, such as breast cancer treatment,
      • Bickell NA
      • et al.
      A tracking and feedback registry to reduce racial disparities in breast cancer care.
      heart failure outcomes,
      • Sisk JE
      • et al.
      Effects of nurse management on the quality of heart failure care in minority communities: a randomized trial.
      and colon cancer screening.
      • Baker DW
      • et al.
      Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: a randomized clinical trial.
      Unfortunately, most of these efforts have been undertaken as special projects, often with time-limited external funding, and the interventions were not sustained or spread within or across organizations.
      A different approach is needed. Health care organizations should have established leaders, structures, and processes in place on a permanent basis to detect and address disparities, just like they do for infection prevention and control, antibiotic stewardship, and workplace violence. The Joint Commission recently developed and published a new accreditation Leadership (LD) standard and associated elements of performance (EPs) for health care equity for hospitals, ambulatory group medical practices, and selected behavioral health centers (see Sidebar 1). The Joint Commission placed this standard in the “Leadership” chapter because success in addressing disparities requires leadership from the highest levels of health care organizations. Efforts to address health care equity should be fully integrated with existing quality improvement activities within the organization so they are on par with other priorities.
      The new Joint Commission accreditation standard focuses on health care disparities rather than the broader issue of health disparities because health care organizations have greater control over health care disparities. We applaud health care organizations that have already gone beyond health care disparities and are working in partnership with communities and community-based organizations to address social determinants of health (SDOH)—for example, education, poverty, inadequate housing—which are root causes of many diseases. However, The Joint Commission thought it would be beyond our usual boundaries to create accreditation requirements for health care organizations to partner with communities to address SDOH. Nevertheless, health care organizations must recognize that the SDOH for a population become health-related social needs (HRSNs) for individuals when they enter the health care system. Even if health care organizations provide recommended diagnostic tests and treatments for their patients, if they do not address their HRSNs, they will not be able to eliminate disparities in health outcomes.
      • Tipirneni R.
      A data-informed approach to targeting social determinants of health as the root causes of COVID-19 disparities.
      • Ogunwole SM
      • Golden SH.
      Social determinants of health and structural inequities—root causes of diabetes disparities.
      • Crear-Perry J
      • et al.
      Social and structural determinants of health inequities in maternal health.
      Understanding individual patients’ HRSNs can be critical for designing practical, patient-centered care plans. A care plan for tight control of diabetes may be unsafe for someone with food insecurity, and outpatient radiation therapy may be impractical for someone who lacks reliable transportation to treatment. Many studies have shown that SDOH and HRSNs can be effectively addressed.
      • Gottlieb LM
      • Wing H
      • Adler NE.
      A systematic review of interventions on patients’ social and economic needs.
      The introduction of specific requirements to address health care disparities is an important step forward, but it should be acknowledged that health care is still learning how to address HRSNs and health care disparities effectively and efficiently. For these reasons, The Joint Commission's standard focuses on fundamental processes that will help organizations start this journey: identifying a leader, understanding patients’ HRSNs, stratifying key measures, developing a plan to address one or more targets, and communicating efforts and progress to stakeholders. The requirements provide flexibility in their scope and focus to accommodate organizations at different stages on the path forward. For example, although it would be ideal for all patients to have their HRSNs assessed so these can be addressed directly or indirectly through a modified treatment plan, the standard does not require screening all patients; our requirement (EP 2) allows organizations to assess HRSNs for a representative sample of their patients rather than all patients. This will allow organizations to understand the value of screening and identify the resources most needed by the people they care for. These requirements will serve as a foundation for future work to address health care disparities and achieve equity. Achieving health care equity will require commitment, vision, creativity, and sustained effort at all levels, including the C-suite and the board.

      Call for Papers

      The Journal has published many articles over the past few years on disparities, HRSNs, and interventions to address these.
      • Imran A
      • et al.
      Improving and promoting social determinants of health at a system level.
      • Olazo K
      • et al.
      Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.

      Ozimek JA, Greene N, Kilpatrick SJ. Lack of Association between race and ethnicity and timely treatment of severe peripartum hypertension. Jt Comm J Qual Patient Saf, forthcoming.

      • Garg A
      • et al.
      Prioritizing child health: promoting adherence to well-child visits in an urban, safety-net health system during the COVID-19 pandemic.
      • Hartford EA
      • et al.
      Changes in rates and modality of interpreter use for pediatric emergency department patients in the COVID-19 era.
      • Malevanchik L
      • et al.
      Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues.
      • Morris MA
      • et al.
      Implementation of collection of patients’ disability status by centralized scheduling.
      • Austin JM
      • Weeks K
      • Pronovost PJ.
      Health system leaders’ role in addressing racism: time to prioritize eliminating health care disparities.
      • Gutman CK
      • et al.
      Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department.
      • Huennekens K
      • et al.
      Using electronic health record and administrative data to analyze maternal and neonatal delivery complications.
      • Rosendale N
      • et al.
      Systematic collection of sexual orientation and gender identity in a public health system: the San Francisco Health Network SO/GI systems-change initiative.
      • Solomon A
      • et al.
      Surgical residents as certified bilingual speakers: a quality improvement initiative.
      • Marshall LC
      • et al.
      Promoting effective communication with limited English proficient families: implementation of video remote interpreting as part of a comprehensive language services program in a children's hospital.
      • Paradise RK
      • et al.
      Reducing the use of ad hoc interpreters at a safety-net health care system.
      • Taira BR
      • Kim K
      • Mody N.
      Hospital and health system–level interventions to improve care for limited English proficiency patients: a systematic review.
      • Ding JM
      • et al.
      A model for improving health care quality for transgender and gender nonconforming patients.
      • Herrin J
      • et al.
      Hospital leadership diversity and strategies to advance health equity.
      • Morris MA
      • et al.
      Development of patient-centered disability status questions to address equity in care.
      • Hefele JG
      • et al.
      Examining racial and ethnic differences in nursing home quality.
      The list includes an article by the winner of the 2021 Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, “Prioritizing Child Health: Promoting Adherence to Well-Child Visits in an Urban, Safety-Net Health System During the COVID-19 Pandemic.”
      • Garg A
      • et al.
      Prioritizing child health: promoting adherence to well-child visits in an urban, safety-net health system during the COVID-19 pandemic.
      To further the mission of the Journal and The Joint Commission and to publish even more articles in the coming years, we are issuing this call for papers.
      We are most interested in original research on interventions to address HRSNs and ameliorate health care disparities. Descriptive studies of how organizations collect HRSN data from patients, store the data in electronic health records, analyze HRSN data, and refer patients to receive social services are also of interest; these should be submitted as Innovation Reports that allow a more flexible format and require less data to show the effectiveness of the systems. Those interested in submitting commentaries or other article types should contact Dr. David Baker, Editor-in-Chief ([email protected]) prior to submission to make sure the commentary is novel and of interest to the Journal’s readers. We encourage authors of original research to also submit their work to be considered for the 2021 Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity, sponsored by The Joint Commission and Kaiser Permanente.
      The Joint Commission. Bernard J
      Tyson National Award for Excellence in Pursuit of Healthcare Equity.
      Finally, articles published in the Journal will be considered for inclusion in the Joint Commission resource compendium that is being created to help health care organizations improve patient care and meet our accreditation requirements (see Sidebar 1, EP 4). In the words of Dr. Jonathan B. Perlin, President and Chief Executive Officer of The Joint Commission, “The Joint Commission must become a standard-bearer for the cause of improvements in health equity and adopt it as a core component of our Mission.” The Journal is striving to help lead this charge, and we look forward to your submissions as we all work to achieve the national goals of health and health care equity.
      Sidebar 1. New Joint Commission Accreditation Leadership (LD) Standard and Elements of Performance (EPs)
      The new standard and its EPs (effective January 1, 2023) will apply to hospitals, critical access hospitals, selected behavioral centers, and ambulatory medical practices.
      Standard LD.04.03.08
      Reducing health care disparities for [the organization's patients / the individuals served by the organization] is a quality and safety priority.
      EP 1
      The [organization] designates an individual(s) to lead activities to reduce health care disparities for [the organization's patients / the population served by the organization].
      Note: Leading the [organization's] activities to reduce health care disparities may be an individual's primary role or part of a broader set of responsibilities.
      EP 2
      The [organization] assesses [the patient's health-related social needs / the health-related social needs of the individual served] and provides information about community resources and support services.
      Note 1: [Organizations] determine which health-related social needs to include in the [patient / individual] assessment. Examples of [a patient's / an individual's] health-related social needs may include the following:
      • Access to transportation
      • Difficulty paying for prescriptions or medical bills
      • Education and literacy
      • Food insecurity
      • Housing insecurity
      Note 2: Health-related social needs may be identified for a representative sample of [the organization's patients / the individuals served by the organization] or for all [the organization's patients / the individuals served by the organization].
      EP 3
      The [organization] identifies health care disparities in [its patient population / the population it serves] by stratifying quality and safety data using the sociodemographic characteristics of [the organization's patients / the individuals served by the organization].
      Note 1: [Organizations] may focus on areas with known disparities identified in the scientific literature (for example, [HAP/CAH: organ transplantation, maternal care, diabetes management; AHC: kidney disease, maternal care, diabetes management; BHC: treatment for substance abuse disorder, restraint use, suicide rates]) or select measures that affect all [patients / individuals] (for example, experience of care and communication).
      Note 2: [Organizations] determine which sociodemographic characteristics to use for stratification analyses. Examples of sociodemographic characteristics may include the following:
      • Age
      • Gender
      • Preferred language
      • Race and ethnicity
      EP 4
      The [organization] develops a written action plan that describes how it will address at least one of the health care disparities identified in [its patient population / the individuals it serves].
      EP 5
      The [organization] acts when it does not achieve or sustain the goal(s) in its action plan to reduce health care disparities.
      EP 6
      At least annually, the [organization] informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce identified health care disparities.
      HAP, Hospital; CAH, Critical Access Hospital; AHC, Ambulatory Health Care; BHC, Behavioral Health Care and Human Services.

      Conflicts of Interest

      The author reports no conflicts of interest.

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