Brief Your CEO: The New Joint Commission Health Equity Standard

Like all providers, labs have an ethical obligation to work toward the goals of eliminating systemic racial, ethnic, and other disparities and ensuring equity in delivering healthcare services to the communities they serve. But now the stakes are raising. As of January 1, 2023, your lab may need to develop and implement a full-blown health equity plan to maintain its Joint Commission accreditation. As compliance manager, you need to brief your CEO and executive management about the new Joint Commission standard and the measures it requires your lab to take. Here’s a set of instructions you can use to prepare your CEO briefing, along with a model health equity commitment statement that you can adapt.

What’s At Stake: Explaining the Inequities in Health Care

First, you need to establish the context. Start by explaining a truth that almost nobody disputes, especially after the COVID-19 pandemic: Racial and ethnic minorities and other socially disadvantaged groups in America have significantly less access to and receive lower quality health care than do White people. To document this, cite U.S. Census Bureau data showing that in 2017, only 5.9 percent of non-Hispanic Whites lacked health insurance, as compared to:

• 10.6 percent of African Americans;
• 7.3 percent of Asian Americans; and
• 14.9 percent of American Indians and Alaska Natives.

Although these inequities have existed for decades, the disproportionately high COVID-19 death rates among non-white racial and ethnic groups during the pandemic laid them bare. It made the elephant in the room impossible to ignore.

The New Joint Commission Health Equity Standard

Having set the context, explain how all of this affects your lab. Let the CEO know that the Centers for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and National Minority Quality Forum (NMQF) have all adopted health equity standards. The CMS model remains a work in progress.

Now, get to the principal point, namely, that the Joint Commission has joined the cause by creating its own standard requiring hospitals and other accredited providers to take meaningful measures to improve equity in health care. “Reducing health care disparities for the [organization’s patients] is a quality and safety priority,” the new standard states.

Provide a general description of the new Joint Commission standard, aka, Standard LD 04.03.0. Note that it largely mirrors the CMS, NCQA, and NMQF models and, more significantly, that it takes effect on Jan. 1. Specify that the standard applies to accreditation programs for:

• 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); 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 Your Lab Must Do to Comply

Now we come to the heart of the briefing, the things your lab will have to do to comply. Tell the execs that the standard incorporates six Elements of Performance (EP) that inspectors will check to ensure an organization’s compliance. Then provide a brief overview of each EP.

1. Designate a Health Disparities Officer

First, be sure your CEO understands that the lab will have to designate an officer to lead the effort to develop and implement a strategy for reducing health disparities experienced by the lab’s patients. The function can be either a dedicated role or part of a broader set of responsibilities.

2. Screen Patients’ Needs

Labs subject to the standard will have to assess patients’ health-related social needs, referred to as “social determinants of health,” that potentially affect their access to and the quality of lab and other healthcare services they receive. List examples of social determinants, including the patient’s:

• Access to transportation;
• Financial situation and ability to pay for tests, prescriptions, or medical bills;
• Education and literacy;
• Food and housing insecurities.

You might want to add that the standard says that covered 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

The third thing your lab may have to do is to actively identify healthcare disparities in its patient population. To comply, the lab will need to stratify its quality and safety data to account for patients’ sociodemographic features, which may include age, gender, preferred language, race, and ethnicity.

4. Implement a Written Action Plan to Eliminate Disparities

If the lab finds no disparities, it can take its foot off the gas—as long as it’s confident that the conclusion and data on which it’s based are sound and continues to perform stratified data analyses on a regular basis, i.e., at least once a year. However, if the analysis does reveal healthcare disparities in its patient population, the lab must create and implement a written plan to address at least one of those identified disparities. How the lab addresses those issues varies depending on the type of organization it’s considered for Joint Commission purposes.

5. Take Follow-Up Action

Next, explain that the lab must take action when it fails to achieve or sustain the goal(s) in its action plan to reduce healthcare disparities. Unfortunately, the standard doesn’t address exactly what type of action is required. The Joint Commission will probably offer more clarification on this issue later.

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.

Takeaway & Compliance Strategy

End the briefing by outlining things your lab can do to ensure that the medical staff is aware of and positioned to comply with new Standard LD 04.03.0 when it takes effect in January. Such steps may include:

• Reviewing medical staff bylaws to ensure they include an express commitment on the part of staff to 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; and
• Training staff on the principles of equity in health, hidden biases that can lead to disparities, and how to recognize and avoid them.

Model Statement of Commitment to Principles of Healthcare Equity

If it hasn’t already, your lab should create a written statement expressing the commitment of its staff to eliminating healthcare disparities and ensuring equity in the services it delivers to all patients. Here’s a template that you can adapt that amalgamates some of the strongest elements of commitment statements from labs and healthcare organizations that have gotten ahead on the equity challenge.

Commitment to Healthcare Equity

All individuals have a fundamental right to receive safe, affordable, high-quality, and equitable health care.

ABC Laboratories provides services to a diverse patient population. They come from all parts of the globe; they speak many different languages; they are of multiple races, ethnicities, religions, ages, and social and economic backgrounds. ABC Laboratories recognizes that these personal characteristics may adversely affect the patient’s access to care and the quality of care they receive.

ABC Laboratories is fully committed to identifying and eliminating these disparities and delivering equitable care to all of its patients regardless of their race, color, national origin, ethnicity, religion, sex, age, ancestry, sexual orientation, gender identity and expression, disability, family or marital status, economic status, source of income, political beliefs, or the language they speak.

To achieve these principles of health equity, ABC Laboratories has adopted a plan for collecting and analyzing high quality data about patients’ race, ethnicity, and language (REAL data) for purposes of identifying healthcare disparities that may impact their access to health care and the quality of the care they receive.

The ABC Laboratories Health Disparities Officer and other staff will perform such analyses of REAL data on an ongoing basis. ABC Laboratories will also initiate specific actions to eliminate disparities that it identifies.

In addition, ABC Laboratories will furnish annual reports to stakeholders detailing the progress it is making in identifying and eliminating healthcare disparities and achieving its ultimate health equity objectives.

ABC Laboratories CEO: ______________________________________________
Signature: _________________________________________________________