Laboratory Accreditation: New Joint Commission Health Equity Standard Takes Effect January 1, 2023

As you plan for compliance in 2023, be aware that your laboratory may have to comply with new Joint Commission accreditation standards designed to eliminate systemic racial, ethnic, and other disparities in healthcare delivery. Here is a briefing of the proposed new equity rule, whom it affects, and the six things it will require you to do.

Addressing Inequities in Health Care

In the US, racial and ethnic minorities have significantly reduced access to and receive lower quality health care than do Caucasian people. For example, according to U.S. Census Bureau data, in 2017, only 6.3 percent of “non-Hispanic Whites” lacked health insurance, compared to

• 10.6 percent of African Americans,
• 7.3 percent of Asian Americans, and
• 14.9 percent of Native Americans and Alaska Natives (2019 data is included here as 2017 data was not listed for these groups).

Although these inequities have existed for decades, the disproportionately high COVID-19 death rates among underrepresented groups during the pandemic laid them bare.

While lawmakers have taken the lead, the nation’s most powerful healthcare accreditation agency, the Joint Commission, has acknowledged its own responsibility to address healthcare inequities. Accordingly, the Joint Commission set out to create a new standard to require hospitals and other accredited providers to take meaningful measures to improve equity in health care.

The New Joint Commission Health Equity Standard

The new Joint Commission standard is similar to health equity standards adopted by other organizations, including the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and the National Minority Quality Forum (NMQF). It will be part of the Joint Commission’s Leadership Standard (LD). The new standard, LD.04.03.08, takes effect on January 1, 2023, and applies to accreditation programs for the following:

• All 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).
• 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.

Six 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 the following:

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 health disparities officer can be either a dedicated role or part of a broader set of responsibilities.

2. Screen Patients’ Needs

Organizations will have to assess patients’ health-related social needs, i.e., social determinants of health, which may include the following:

• 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 a 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.

How to Comply

To ensure compliance and avoid citations, the medical staff of covered laboratories must be aware of and take steps to prepare for the new standard, LD.04.03.08, before it goes into effect. Such steps may include the following:

• Reviewing medical staff bylaws to ensure they include an express commitment from staff to uphold the principles of equity and the identification and elimination of disparities in health care.
• Creating a subcommittee or medical staff position responsible for leading the effort, in coordination with other organizational leaders, to perform screening and develop action plans to eliminate identified disparities.
• Establishing a mechanism for annual reporting on progress toward achieving health equity goals and reducing disparities.
• Training staff on the principles of equity in health, hidden biases that can lead to disparities, and how to recognize and avoid them.

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This article originally appeared in G2 Intelligence, Diagnostic Testing & Emerging Technologies, October, 2022.