Preparing For The Joint Commission's New Health Care Equity Certification

The Joint Commission will launch its new Health Care Equity (HCE) certification on July 1, 2023. This advanced certification program recognizes hospitals and critical access hospitals that strive for excellence in providing equitable care, treatment, and services.

In early 2023, pre-publication requirements were distributed emphasizing the structures and processes that healthcare organizations should have in place to support healthcare equity and reduce health disparities. This optional certification is a critical next step for achieving more equitable care delivered by the foundation of US healthcare, the hospital.

Health Care Equity Certification requirements overview

The new HCE certification extends The Joint Commission's commitment to safe, high-quality healthcare for all and entails healthcare equity topics across 5 domains:

1. Leadership
2. Collaboration
3. Data collection
4. Provision of care
5. Performance improvement

The Joint Commission plans to double down its health equity efforts. In addition to establishing the HCE certification, the institution has announced the Leadership (LD) Standard is being elevated to a new National Patient Safety Goal^® (NPSG). Known formally as LD.04.03.08, LD focuses on healthcare disparities as a quality and safety priority with requirements around identifying individuals with social needs, assessing and analyzing disparities, developing an action plan, and reporting on progress.

While the new NPSG will not affect the HCE requirements, it does reinforce an increased focus on "improving healthcare equity versus reducing healthcare disparities." Together, these initiatives highlight a provider organization's commitment to and efforts toward addressing disparities as a quality and safety priority. Below we take a closer look at each of the domains addressed in the HCE certification.

1. Leadership

The first leadership standard requires that an organization has established healthcare equity as a strategic priority. Elements of performance include board actions, financial allocations, and a documented health equity strategic plan (HCELD.01).

An additional leadership element requires that the organization define specific leadership roles and that these positions have administrative leadership and oversight, as well as plan and manage activities to achieve the organization's health equity goals (HCELD.02).

2. Collaboration

Collaboration is a key component of the new HCE certification. The Joint Commission requires that the organization collaborates with patients, families, caregivers, and community organizations to support healthcare equity. The organization must demonstrate that they identify patient-level and community-level needs that they are working to address through processes, policies, and procedures, supporting equitable healthcare delivery (HCECL.01).

3. Data collection

Organizational changes to deliver more equitable care often rely on accurate data. Therefore, the certification requires that an organization engages data about the community it serves to identify opportunities to improve healthcare equity. Evidentiary documentation of performance could include a community health assessment or review of sociodemographic characteristics and social needs found in government datasets or social risk indices (HCEDC.01).

A second type of data emphasized in the certification program is self-reported data. The element HCEDC.02 requires collecting self-reported patient data to uncover opportunities where the organization could improve healthcare equity. Several documents can be used to demonstrate performance, including medical records that show the patient's race, ethnicity, and preferred language. Medical records should also display information about social needs and any physical, mental, communication, or cognitive accommodations needed. Documentation should also indicate how the organization identifies incidents and perceptions of discrimination and bias experienced by patients.

Finally, the Joint Commission requires that the organization collects self-reported data from its staff and leaders to identify opportunities to improve healthcare equity, similar to how information is collected from patients (HCEDC.03).

4. Provision of care

To earn the certification, the organization must document that they support diversity, equity, and inclusion for its staff and leaders. Elements of performance focus on prohibiting discrimination against staff and leaders and implementing policies and procedures around employee recruitment and retention so that staff and leaders reflect community diversity (HCEPC.01).

Further, the organization is required to provide staff with the education and training necessary to provide equitable care, treatment, and services, including the relationship between health-related social needs and healthcare disparities, as well as sensitivity training (HCEPC.02).

Effective communication with patients and families, including a process to provide qualified interpreters, assess staff language proficiency, and support patients with health literacy materials in an understandable format is covered in requirement HCEPC.03, and requirements for the organization to accommodate patients with physical, mental, communication, or cognitive disabilities is covered in HCEPC.04. This could include removing physical barriers, providing auxiliary or supportive equipment, and providing additional time for healthcare discussions.

HCEPC.05 requires processes to identify, review, and address health-related social patient needs in collaboration with community and social service agencies.

5. Performance improvement

A key aspect of all quality improvement programs and accreditation is that organizations conduct performance improvement. The new Health Care Equity certification requires that organizations carry out at least an annual data analysis to identify opportunities to improve equitable care, treatment, and service delivery. Performance elements include reviewing data from sociodemographic sources and a complaint resolution process. Additionally, the organization should stratify experience of care measures and stratify at least 3 relevant quality or safety measures (HCEPI.01). A second performance improvement element, HCEPI.02, requires health equity improvement efforts to address diversity, equity, and inclusion for staff and leaders. This should include comparing staff, leadership, and community languages. Additionally, the organization should document how it stratifies data from any culture of safety and employee opinion surveys on diversity and inclusion.

Monitoring and preliminary preparation for HCE certification

Throughout Spring 2023, RTI Health Advance and our consultants will provide additional details and guidance to support the pre-application process once it opens. Our experts walk alongside hospital leaders and staff to identify and gather adequate documentation and evidence to demonstrate full compliance.

Beyond certification, we help provider organizations in their quest to strengthen health equity programs through our proprietary social risk index, data analysis, community engagement, and population health initiatives. Contact us.