August 18, 2022

As of January 1, 2023, the Joint Commission’s Accreditation Standards will include requirements on health equity for ambulatory health care, behavioral health care and human services, critical access hospital, and acute-care hospital accreditation programs. The move comes after the Joint Commission originally released an advisory for health care leaders to make health equity a strategic priority back in July 2021. The Joint Commission Standards, which are similar to those adopted by CMS, the National Committee for Quality Assurance, and the National Minority Quality Forum, are reflected in the following Standards: Leadership (LD), Rights and Responsibilities of the Individual (RI) and Record of Care, Treatment and Services (RC).

The new LD Standard provides: “Reducing health care disparities for the [organization’s] [patients] is a quality and safety priority.” The new Standard LD.04.03.0 will apply to ambulatory health care, behavioral health care and human services, critical access hospital services, and acute care hospital services. The Standard includes the following Elements of Performance (EP):

  1. Designating an officer to lead a strategy for reducing health disparities.
  2. Screening patients for health-related social needs, also referred to as social determinants of health.
  3. Developing a written action plan that describes how it will address at least one of the health care disparities identified in its patient population.
  4. Identifying health care disparities in its patient population by stratifying quality and safety data using the sociodemographic characteristics.
  5. Acting when it does not achieve or sustain the goal(s) in its action plan to reduce health care disparities.
  6. At least annually, informing key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce identified health care disparities.

The current acute care hospital Standard RI.01.01.01 that focuses on how organizations respect the rights of patients during their encounter by treating them in a dignified and respectful manner will apply to additional providers starting January 1, 2023. In addition to hospitals, Standard RI.01.01.01, EP 29 states:

“The organization prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.”

Standard RI.01.01.01, EP 29 will also apply to all Joint Commission accredited ambulatory health care organizations, critical access hospitals, and behavioral health care and human services organizations.

Additionally, the current hospital Standard RC.02.01.01, EP 25 relating to collection of patient race and ethnicity information will be included as a new EP for other providers. In addition to hospitals, the EP will now also apply to ambulatory health care, behavioral health care, and critical access hospitals. Citing the CMS Health Disparities Guide, the Joint Commission indicated that collecting this information for each patient allows organizations to better understand the patient population it serves and allows organizations to stratify key quality and safety measures to identify potential disparities in care.

The Joint Commission has posted an accompanying R3 Report on its rationale for adopting these changes along with several resources and FAQ’s on best practices for meeting elements of performance on its website located here.

Organizations subject to the new requirements regarding health equity will be required to track progress on their adopted health equity plans and document that status updates have been passed on to internal leadership and that leadership takes appropriate action to meet the goals of adopted plans. The Joint Commission’s new health equity requirements under Standards LD, RI, and RC are aimed at holding health care leaders accountable for the organization’s interaction with the communities it serves thereby reducing health care costs.

If you have any questions or need further guidance regarding the Joint Commission’s or other accreditation and regulatory requirements concerning health equity, please contact a member of Hancock Daniel’s Compliance team.

Click here for a full PDF version of this advisory.

The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson, P.C., is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel & Johnson, P.C. be liable for any direct, indirect, or consequential damages resulting from the use of this material.

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