Health Equity Elevated to a Joint Commission National Patient Safety Goal

TJC has emphasized the importance of improving health equity as a component of patient safety, and recently, it took efforts to emphasize that importance to its accredited organizations. Effective July 1, 2023, TJC will elevate Leadership Standard 04.03.08 (LD.04.03.08), which became effective January 1, 2023, and addresses healthcare disparities as a quality and safety priority, to a new National Patient Safety Goal 16.01.01 (NPSG.16.01.01) for the following TJC-accredited organizations:

• All critical access hospitals and hospitals
• Ambulatory healthcare organizations that provide primary care within the “Medical Centers” service in the ambulatory healthcare program
• Behavioral healthcare and human services organizations that provide “Addiction Services,” “Eating Disorders Treatment,” “Intellectual Disabilities/Developmental Delays,” “Mental Health Services” and “Primary Physical Health Care Services.”

According to a TJC R³ Report that was published in June 2022, LD.04.03.08 was originally placed in TJC’s Leadership Standard category to highlight that health equity requires commitment, vision, creativity and sustained effort at all levels of leadership within an organization, including the C-suite and the board of directors. Shifting the TJC category from Leadership Standard to National Patient Safety Goal does not necessarily change this view, however, according to the report, TJC considers the latter category to be better fitting since its purpose is to improve patient safety with a focus on significant healthcare problems and specific actions to prevent and solve them. This places health equity on par with other National Patient Safety Goals that aim to reduce the likelihood of patient harm, such as medication safety and surgical error prevention.

The shift in category also comes with some minor modifications to the original elements of performance. While the intent behind the standard and elements remains the same, there is heightened focus on health equity rather than on reducing healthcare disparities.

NPSG.16.01.01 elements of performance will be as follows:

• Identify an individual to lead activities to improve healthcare equity
• Assess the patient’s health-related social needs
• Analyze quality and safety data to identify disparities
• Develop an action plan to improve healthcare equity
• Act when the organization does not meet the goals in its action plan
• Inform key stakeholders about progress to improve healthcare equity.

This development builds upon TJC’s focus on health equity during the COVID-19 era. Per TJC’s health equity website, these Leadership Standards and National Patient Safety Goals are among the first of their kind and will help create a consistent national baseline related to the equitable delivery of care. TJC-accredited and some non-TJC-accredited hospitals and critical access hospitals wishing to demonstrate greater efforts in achieving health equity may be interested in pursuing advanced Health Care Equity certification from TJC. Eligible non-TJC-accredited hospitals and critical access hospitals must comply with applicable federal laws, including the Centers for Medicare and Medicaid Services’ (CMS) Conditions of Participation (CoPs). Effective July 1, 2023, this certification will be available upon demonstration that efforts by hospitals and critical access hospitals provide equitable care, treatment and services. Standards for advanced certification are not yet published but can be requested from TJC. Organizations may pre-apply for certification in early 2023.

As TJC is subject to promulgating standards that align with CMS’s CoPs, we anticipate that TJC health equity standards will align with the 2022 CMS Proposed Rules, implementing and further reinterpreting Section 1557 of the Affordable Care Act, which may be complicated if the Proposed Rules are finalized after these new standards are made effective July 1, 2023.