Improving equity in health care continues to be a top national priority. In addition to federal initiatives 1 that require ongoing attention to improving health equity by reducing health disparities, The Joint Commission (“TJC”) recently adopted new requirements intended to improve health equity. TJC first announced standards to reduce health disparities (effective January 1, 2023) as part of the leadership accreditation standards.2 TJC placed the standards in the leadership chapter “because success demands leadership” and “achieving healthcare equity will require commitment, vision, creativity and sustained effort at all levels, including the C-Suite and the Board.”3 Shortly thereafter, TJC announced that the content of the leadership standard (LD.04.03.08) would be elevated to a new National Patient Safety Goal (“NPSG”).4 The elevation of health equity as a NPSG should come as no surprise.5 In the U.S., outcomes data related to health equity continues to challenge and highlight the need for change in the delivery of health care.6 In the new standard, TJC is directing organizations to improve health equity as a NPSG. 

To fully appreciate TJC directive, the following definitions are important to understand:7

• Health equity means that “everyone has a fair and just opportunity to attain the highest level of health.”8
• Health disparities are “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by populations that have been disadvantaged by their social or economic status, geographic location, and environment.”9
• Health related social needs (“HRSN”) are an “individual’s unmet, adverse social conditions . . . that contribute to poor health and are a result of underlying social determinants of health (conditions in which people are born, grow, work and age)”.10

The new NPSG 11 (Goal 16) applies to behavioral health and human resources organizations providing the following services: addiction services, eating disorders treatment, intellectual disabilities/developmental delays, mental health services, and primary physical health care services.12 There are six elements of performance (“EP”) identified to further the goal of improving health equity:

1. The first EP requires organizations to designate an individual to lead organizational activities to improve health equity for the population served by the organization.13 The designated individual may have this accountability as the individual’s primary role or it may be part of other job duties.14 Importantly, each separately licensed facility will need an identified individual who is responsible to lead health equity.15
2. The second EP requires the organization to assess the individual’s HRSN and provide information about community resources and support services.16 To meet this PE, an organization should engage in a three part analysis to determine which HRSNs to include in an assessment, which individuals to include (all or a representative sample of individuals served) and what information about community resources and support services is available to target the HRSN.17 TJC stresses that there is flexibility for an organization in selection of HRSNs.18
3. The third PE requires an organization to identify health care disparities in the population it serves by stratifying quality and safety data using the sociodemographic characteristics of the individual’s served.19 An organization has flexibility to either rely on known health disparities identified in the scientific literature20 or may rely on the results of organization’s disaggregation of its own data. It is important to understand the barriers in order to design appropriate interventions as discussed below.
4. The fourth PE requires the organization to develop a written action plan that describes how it will improve health equity by addressing at least one of the health care disparities identified in the organization’s population.21 The action plan should identify the organization’s improvement goal, the strategies and resources needed to achieve the goal, and the process that will be used to monitor and report progress. 22
5. The fifth PE requires the organization to act if it does not achieve or sustain the goal(s) in its action plan to improve health equity.23 This creates a continuous process improvement expectation and requires the identification of follow-up actions as needed.24
6. The sixth and final PE requires a process to inform key stakeholders at least annually of the organization’s progress to increase health equity.25 Key stakeholders include organizational leaders, licensed practitioners, staff and governing bodies.26

As your organization executes on these PE (effective July 1, 2023) it may be helpful to consider the original guidance offered when TJC first announced the leadership standard prior to elevating the standards to a NPSG because TJC does not view the content of the NPSG as changing significantly from the leadership guidance. Rather, TJC continues to rely upon the existing body of research reflect in the leadership review, public field review and expert engagement.27 TJC’s earlier view that success demands leadership is undoubtedly unchanged. While there are many non-financial resources available to organizations seeking to improve health equity, TJC offers an approach that allows every organization to start the journey. TJC’s approach relies on integration of health equity into an organization’s quality improvement activities just like any other safety and quality priorities. 

The opportunities for meaningful progress are significant and your organization’s efforts to understand the root causes of inequity and address those root causes with targeted interventions is critical. Using established quality improvement processes is crucial to advancing health equity and creates an important education and training opportunity within your workforce to elevate an understanding of health equity across an organization. Further, health inequities drive low value care (i.e., poor outcomes and variations in the cost of care). 28 While value-based care initiatives that are aligned with the “Triple Aim” of improving the care experience of the individual, the health of populations and reducing per capita costs of care are conceptually aligned with the goal of reducing health inequities, in practice value-based care has not always demonstrated improvement.29 The new NPSG creates an opportunity to do better with a more targeted focus on reducing inequity, a goal which continues to have the potential to reduce variations in costs and health outcomes.30 There are clear opportunities for investors, providers and payers to engage more deeply in the interplay between inequity, cost and outcomes to build targeted interventions that do not further exacerbate inequity. Partnership with community organizations engaged in work to reduce health disparities through addressing HRSN will be critical.

1 CMS and other federal agencies are creating frameworks and regulatory expectations related to improving health equity. https://www.cms.gov/ priorities/health-equity/minority-health/equity-programs/framework. See also the CDC’s approach and efforts to harmonize terminology across federal agencies and others. https://www.cdc.gov/healthequity/index.html#:~:text=Health%20equity%20is%20the%20state,their%20highest%20 level%20of%20health. Unique to behavioral health, CMS recently announced a new innovation model that requires behavioral health practice participants to conduct screenings for health-related social needs and to refer patients to appropriate community-based services. https://www.cms.gov/priorities/ innovation/innovation-models/innovation-behavioral-health-ibh-model. See also Kathleen Snow Sutton, Rise of Value-Based Care: Integration and Coordination within this Newsletter.

2 R3 Report Issue 36: New Requirements to Reduce Health Care Disparities, June 20, 2022, The Joint Commission. https://www.jointcommission.org/-/ media/tjc/documents/standards/r3-reports/r3_disparities_july2022-6-20-2022.pdf

3 Id. TJC recognized that many organizations’ efforts at health equity were project driven and even when successful, lacked an institutional leadership focus.

4 R3 Report Issue 38: National Patient Safety Goal to Improve Health Equity, December 20, 2022, The Joint Commission. https://www.jointcommission. org/-/media/tjc/documents/standards/r3-reports/r3_npsg-16.pdf. As background, the National Patient Safety Goal (“NPSG”) program was established in 2002 and helps organizations address specific areas of concern regarding patient safety.

5 See supra Note 1.

6 Racial Equity and Health Policy. https://www.kff.org/racial-equity-and-health-policy/. The Kaiser Family Foundation tracks and publishes data on disparities on health data based on race and ethnicity and other key metrics related to health equity. The research consistently demonstrates that people of color experience poorer health outcomes than others. Id.

7 There continues to be slight variations in definitions, depending on the source and ongoing evolution concerning what terminology best achieves the goals identified. For example, the Centers for Medicare and Medicaid (“CMS”) recently endorsed the term “drivers of health” (“DOH”) as preferred terminology over “social determinants of health” noting that the term minimizes confusion, misinterpretation and negative connotations. 87 FR 69404 at 70054-55. See also Melinda K. Abrams, Rachel Nuzum, Debbie I. Chang and Rocco Perla, Let’s Get It Right: Consistent Measurement of Drivers of Health, The CommonWealth Fund. https://www.commonwealthfund.org/blog/2023/lets-get-it-right-consistent-measurement-drivers-health.

8 The Center for Disease Control and Prevention offers several definitions as part of its public health mission. https://www.cdc.gov/healthequity/index. html#:~:text=Health%20equity%20is%20the%20state,their%20highest%20level%20of%20health.

9 Id.

10 Elizabeth Hinton, A Look at Recent Medicaid Guidance to Address Social Determinants of Health and Health-Related Social Needs. (February 22, 2023) available at Kaiser Family Foundation. https://www.kff.org/policy-watch/a-look-at-recent-medicaid-guidance-to-address-social-determinantsof-health-and-health-related-social-needs/. The TJC, in its HRSN screening guidance, provides examples of the primary HRSN domains to include as food insecurity, housing instability, transportation challenges, education and literacy and difficulty paying for prescriptions or medical bills. TJC focuses on HRSN, rather that social determinants of health “to emphasize that HRSNs are a proximate cause of poor health outcomes for individual patients. . . .” R3 Report Issue 38: National Patient Safety Goal to Improve Health Equity, December 20, 2022, The Joint Commission. https://www.jointcommission.org/-/ media/tjc/documents/standards/r3-reports/r3_npsg-16.pdf. See also NPSG.16.01.01.

11 R3 Report Issue 38: National Patient Safety Goal to Improve Health Equity, December 20, 2022, The Joint Commission available at https://www. jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_npsg-16.pdf. See also NPSG.16.01.01.

12 Id.

13 Id. Performance Element 1

14 Id.

15 Id.

16 Id. Performance Element 2.

17 At an individual level, HRSNs may include access to transportation, difficulty paying for prescriptions, education and literacy, food insecurity, or housing insecurity. Id.

18 Id. Flexibility may be helpful for organizations just beginning this work. However, there are others who advocate for greater tracking consistency, particular among public payers of health care. See Infra Note 7.

19 Examples include age, gender, preferred language or race and ethnicity. Id.

20 Examples include treatment for substance abuse disorder, use of restraints, or suicide rates. Id. Performance Element 3.

21 Id.

22 Id.

23 Id. Performance Element 5.

24 Id.

25 Id. Performance Element 6.

26 While not specifically mentioned in the NPSG, the governing body was a focus of the former leadership standards and should be included in this reporting as a matter of quality oversight accountabilities.

27 Id. In fact, both the leadership standard and the NPSG have identical published research underpinning both, starting with the Institute of Medicine’s twenty-year-old “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.”

28 Pinnock C, Rothen J, Carlough T, Shah NR. Improving value for underserved populations with a community-based intervention: a retrospective cohort study. Arch Public Health. 2023 May 29;81(1):96. doi: 10.1186/s13690-023-01117-z. PMID: 37248512; PMCID: PMC10225756.

29 Amanda Shi, MPH, MPA, Tiara Ranson, MPHc, Julie Chinitz, JD, Karina Patel, MPH, and Danisha-Jefferson Abye, MPH, Sustaining a CommunityDesigned Model of Care: Exhisitng Payment Lnadscare and Opportunities to Address Structural Drivers of Inequity (February 2024) available at https:// tubmanhealth.org/payment-models-report/ The authors noted that “while promising in theory, value-based purchasing and care in practice has not lived up to its equity aspirations in transforming healthcare and instead contributed to the further medical marginalization of populations most impacted by existing health disparities.”

30 See Supra Note 28 (estimating that social determinants of health are “increasingly seen as an underlying driver of up to 30-80% of variation in health outcomes and costs”).