A new Joint Commission standard designed to eliminate systemic racial, ethnic, and other disparities in healthcare delivery takes effect on January 1, 2023. Here’s a briefing on what you must do to comply.
Joint Commission Standard LD 04.03.0
New Standard LD 04.03.0 applies to accreditation programs for:
- Critical access hospitals and hospitals;
- Ambulatory healthcare organizations providing primary care within the “Medical Centers” service in the ambulatory healthcare program (the requirements do not apply to organizations providing episodic care, dental services, or surgical services); and
- Behavioral healthcare and human services organizations providing “Addictions Services,” “Eating Disorders Treatment,” “Intellectual Disabilities/Developmental Delays services,” “Mental Health Services,” and “Primary Physical Health Care” services.
The 6 Things You Must Do to Comply
“Reducing health care disparities for the [organization’s patients] is a quality and safety priority,” the new LD Standard states. It incorporates six Elements of Performance (EP) that inspectors will check to ensure an organization’s compliance, including:
1. Designate a Health Disparities Officer
First, the organization must designate an officer to lead a strategy for reducing health disparities experienced by its patients. The function can be either a dedicated role or part of a broader set of responsibilities.
2. Screen Patients’ Needs
Organization will have to assess patients’ health-related social needs, aka, social determinants of health, which may include:
- Access to transportation;
- Difficulty paying for prescriptions or medical bills;
- Education and literacy;
- Food and housing insecurities.
Organizations may assess a representative sample to determine patients’ health-related social needs, rather than screen each patient individually.
3. Use Stratified Data to Identify Disparities
Organizations must also identify healthcare disparities in their patient population by stratifying quality and safety data accounting for patients’ sociodemographic features, which may include age, gender, preferred language, race, and ethnicity.
4. Implement Written Action Plan to Eliminate Disparities
Organizations must create and implement a written plan to address at least one of the healthcare disparities that they identify in their patient population. How many of these issues must be addressed varies by provider type:
5. Take Follow-Up Action
The organization must take action, which the standard does not describe, when it fails to achieve or sustain the goal(s) in its action plan to reduce healthcare disparities.
6. Provide Annual Progress Reports
The final EP is informing key stakeholders, including leaders, licensed practitioners, and staff, of the organization’s progress in reducing identified healthcare disparities at least once a year.