New Hospital Accreditation Standards for Health Equity

As the quest for health equity gains momentum, the nation’s oldest and largest healthcare evaluation and accreditation body has announced new standards designed to reduce disparities, declaring equity “a quality and safety priority.”

The Joint Commission’s new requirements, announced in August and set to take effect January 1, affect accreditation programs for hospitals, critical access hospitals, ambulatory care, behavioral healthcare and human resources. They call for targeted interventions to be “fully integrated with existing quality improvement activities within the organization like other priority issues such as infection prevention and control, antibiotic stewardship and workplace violence.”

Compliance will surely mean a realignment of priorities and resources for many other organizations. The independent, not-for-profit commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States. That includes nearly 80% of U.S. hospitals, according to a 2017 report by The Wall Street Journal.

What Accreditation Means

While accreditation is voluntary, evidence consistently shows that accreditation programs improve the care process and clinical outcomes. It may also boost public confidence in a healthcare organization.

“Many people look for Joint Commission accreditation as a sign that a hospital has high standards of patient care and safety,” according to a 2017 Healthcare Dive brief following up on The Wall Street Journal’s critical report, which noted the infrequency of revoked or altered accreditations by the commission.

The independent, not-for-profit commission and the Centers for Medicare & Medicaid Services (CMS) share a goal of ensuring compliance with federal standards for healthcare quality and patient safety. Michael Hansen, a patient relations representative at MetroHealth Medical Center in Cleveland, Ohio, writes in a November 2020 blog for The Beryl Institute that The Joint Commission had “fixed its standards based on CMS guidelines and, in some cases, exceeds established federal requirements. … Getting accredited by The Joint Commission guarantees your facility also meets CMS standards.” (The Beryl Institute, an independent global community of healthcare professionals, is committed to improving the patient experience.)

In comparing and contrasting the respective survey approaches of The Joint Commission and CMS, Hansen explains that, while CMS surveyors tend to focus more on assessing documentation than on patient care areas, their commission counterparts use “tracer methodology” to track the care a patient receives. “The results of surveys from both organizations can affect a hospital’s ability to receive Medicare and Medicaid funds,” he writes.

The Joint Commission touts numerous benefits of commission accreditation, including help organizing and strengthening patient safety efforts; improved risk management and reduction; potentially lower liability insurance costs; education to improve business operations; and a customized, intensive review. Hospitals that want to participate in the commission review process must be members and pay a fee.

In Pursuit of ‘The Highest Level of Health’

CMS defines health equity as “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, and other factors that affect access to care and health outcomes.”

On the other hand, inequities, as the Centers for Disease Control and Prevention (CDC) notes, “are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.”

As has become glaringly apparently in recent years, not all demographics have access to the same level of care. Groups particularly affected by disparities include:

• Black and Hispanic people
• Women
• Older adults
• People with disabilities
• Other historically marginalized groups, including non-English speakers and LGBTQ people

Although these disparities have existed for years, the COVID-19 pandemic has pushed them into the spotlight. For example, racial and ethnic minority groups have consistently suffered more severe outcomes, including death, from COVID-19 than white people have. The Biden administration has made racial health equity a priority.

New Accreditation Requirements

“Although health care disparities are often viewed through the lens of social injustice, they are first and foremost a quality of care problem,” The Joint Commission says in its R³ Report | Requirement, Rationale, Reference, issued in June. “Like medication errors, health care-acquired infections, and falls, health care disparities must be examined, the root causes understood, and the causes addressed with targeted interventions.”

To that end, the commission’s new “elements of performance” call on each provider organization to:

1. Designate a leader or leaders of efforts to reduce disparities.
2. Assess its patients’ health-related social needs^* and provide information about community resources and support services.
3. Identify healthcare disparities in its patient population by stratifying quality and safety data using sociodemographic characteristics.
4. Develop a written action plan describing how it will address at least one of the disparities identified in its patient population.
5. Act when it does not achieve or sustain the goals in its action plan.
6. Inform key stakeholders, including leaders, licensed practitioners and staff, at least once a year about its progress to reduce identified disparities.

^* The commission uses the term “health-related social needs” instead of social determinants of health “to emphasize that HRSNs are a proximate cause of poor health outcomes for individual patients as opposed to SDOH, which is a term better suited for describing populations.”

Easing the Burden

As The Joint Commission refocuses its efforts on eliminating disparities, it is mindful of healthcare professionals overwhelmed by reporting requirements. Like the CMS and other regulators, it is working to “ease the compliance burden and to waive quality requirements deemed unnecessary,” Modern Healthcare reported in September. The commission plans to announce in January the first set of major standards to be retired.

“We asked ourselves, ‘If everything is important, then what is really important?’” Joint Commission President and CEO Jonathan Perlin said. “How would we look at our standards and identify those that are most meaningful in driving safety, quality, equity and value?”

Even for hospitals that are not a commission accredited hospital or seeking to be, The Joint Commission’s goals and guidelines are worthy of attention. While they may require some organizations to refocus the lens through which they view what they do, health equity is not only the law but also the right thing to do. And it ultimately makes financial sense.

Medecision is fully committed to quality, safety and equity in healthcare. We would welcome the opportunity to discuss how we might help your organization improve its performance in these vital areas.