The New Jersey Hospital Association

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DISCLAIMER

The New Jersey Hospital Association (NJHA) has organized this toolkit using federal, state and stakeholder sources, with up-to-date standards and recommendations at the time of publication. It has been developed by NJHA for the sole use of NJHA and its members, to assist with implementation of the new health equity standards. NJHA does not intend to provide this information to be utilized as legal, regulatory or compliance advice, and all information should be considered in consultation with legal counsel, regulatory and compliance officers.

OBJECTIVES

The objectives of this toolkit are to

Assist health systems and hospitals in meeting the Hospital Accreditation Standards established by The Joint Commission that address health equity;
Provide resources to support health systems and hospitals in making equity a priority in care delivery;
Collaborate and share evidence-based interventions that have successfully addressed disparities within clinical conditions at their organizations.

QUICK LINKS

Use these links to navigate through the resource:

INTRODUCTION

“Every patient deserves the right to safe, equitable health care. All health care organizations have a responsibility to identify and address the disparities that their unique patient populations face.”
Dr. Jonathan B. Perlin, MD, PhD, president and CEO, The Joint Commission

NJHA developed The Joint Commission Health Equity Standards: A Readiness Toolkit to help guide the user to resources provided by The Joint Commission to assess organizational compliance with the new 2023 health equity standards, and to access relevant resources that may be useful for implementation to meet current gaps.

The Leadership Standards and Elements of Performance (EPs) from TJC 2023 Hospital Accreditation Manual will be used in this toolkit to guide the reader to related resources that can assist in evaluation and/or implementation of changes to meet the standard.

Standard LD.04.03.08: Reducing health care disparities for the [organization’s] [patients] is a quality and safety priority.

EP 1: The [organization] designates an individual(s) to lead activities to reduce health care disparities for the [organization’s] [patients].

TJC has placed the goal of reducing health care disparities under the Leadership Chapter to establish the clear line of accountability to the Board and C-Suite.

Resources include articles on recruiting for a Diverse HealthCare Board from the AHA Trustee Services, a collection of IHI resources on Health Equity and toolkits on equity and diversity.

EP 1 Resources

Make Health Care Equity a Leader-Driven Priority | The Joint Commission

Health Care Equity Certification: Leadership Chapter | The Joint Commission

Requirement:

EP 2: The [organization] assesses the [patient’s] health-related social needs and provides information about community resources and support services.

This will also be important to be documented in the EMR. Two of the highly recommended screening tools PRAPARE and the CMS Health-Related Social Needs (HRSN) Screening Tool from the Accountable Health Communities Model.

EP 2 Resources

Assess Health-Related Social Needs | The Joint Commission

Health Care Equity Certification: Provision of Care Chapter | The Joint Commission

Requirement:

EP 3: The [organization] identifies health care disparities in its [patient] population by stratifying quality and safety data using the sociodemographic characteristics of the [organization’s] [patients].

Effective data analysis can provide insights into which factors contribute to health disparities and how to respond. Data collection includes race, ethnicity, preferred language and LGBT+. Stratification also can be done by diagnoses and procedure codes to determine what specific areas may be of priority in certain locations where each hospital provides care.

EP 3 Resources

Use Data to Identify Disparities Across Patient Groups | The Joint Commission

Health Care Equity Certification: Data Collection Chapter | The Joint Commission

Requirement:

EP 4: The [organization] develops a written action plan that describes how it will address at least one of the health care disparities identified in its [patient] population.

The goal is to evaluate quality of care and performance improvement and always include equity metrics in the project. Successful quality improvement will require attention to this detail from the initial project plan, data definition, collection and measurement, and analysis, and continue to the interpretation, findings and conclusions.

EP 4 Resources

Prioritize, Plan and Take Action | The Joint Commission

Health Care Equity Certification: Performance Improvement Chapter | The Joint Commission

Requirement:

EP 5: The [organization] acts when it does not achieve or sustain the goal(s) in its action plan to reduce health care disparities.

Continuous quality improvement will address the organization’s performance related to the health equity plan. Resources such as dashboards, evaluation of program samples and methods to develop targets are examples of resources available.

EP 5 Resources

Monitor Progress in Achieving Health Care Equity | The Joint Commission

Health Care Equity Certification: Collaboration Chapter | The Joint Commission

Requirement:

EP 6: At least annually, the [organization] informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce identified health care disparities.

Communication in regard to the progress of the health equity plan can be addressed in a variety of ways, at a minimum on an annual basis to key audiences. Examples are provided in reports and videos to see how different organizations effectively share progress on their individual equity plans.

EP 6 Resources

Inform Key Stakeholders About Progress to Reduce Disparities | The Joint Commission

Evidence-Based Interventions

In addition to the Elements of Performance resources, The Joint Commission has identified some evidence-based interventions that have been successful in addressing disparities.

Organizations seeking to reduce health disparities related to a specific clinical condition can access intervention information to assist them in study replication and implementation. All selected interventions meet the following criteria:

Published in a reputable peer-reviewed journal
Randomized controlled trial methodology
Conducted with adequate sample sizes to conduct analyses
A well-defined patient population
Study is replicable
Use of clinical outcome measures directly related to the clinical topic
Yielded statistically significant results showing sustained effectiveness over time

The Joint Commission is steadily adding more topics and intervention materials to their site. If you know of important interventions that have been rigorously evaluated and published, TJC requests that you let them know by emailing HCEResources@jointcommission.org.