Are You Assessing Your Organization for Healthcare Equity Practice?

The focus on healthcare equity has been on the radar for several years.  Most recently, The Joint Commission established new standards in January 2023 regarding organizational responsibilities in identifying and addressing areas of care where disparities may exist.  This was soon elevated that same year to a National Patient Safety Goal, (NPSG) that requires organizations to improve healthcare equity as a patient quality and safety priority.  Information from the Centers for Medicare and Medicaid Services (CMS) indicates that attention to healthcare equity will continue to be a major focus in the years to come, especially with regard to access to care.

Organizations have had 18 months to implement these new standards.  However, our team has noted that some organizations have struggled with fully implementing the requirements.  Have you assessed your current program’s status?  What has your data really told you regarding your organization’s provision of healthcare in an equitable fashion?  Although the new NPSG was limited in the scope of the requirement, there is a strong possibility that this requirement may broaden in scope.  Has implementing the new NPSG standard prepared your organization for a broader review of your processes and practices?

Our team has assessed organizations' compliance with healthcare equity regulations and identified several opportunities.

Designation of Program Oversight:

Organizations have done well with designating responsibility in leading activities focused on improving healthcare equity.  However, during discussions with many of these individuals, there seems to be an overall lack of understanding regarding the program requirements and how to use data to drive their program.  Most organizations have the program oversight assigned to an individual who is in charge of other responsibilities, which is acceptable.  With program oversight assigned to individuals who may not be closely associated with the Quality Department or resources with an organization’s process improvement specialist, we have often seen them struggle with how to analyze data better, identify trends/opportunities, and implement mitigating or improvement strategies.

The most successful robust health equity programs are those with assigned leaders who are trained in the intent and rationale of the program and in process improvement methods and techniques.  Furthermore, leadership must ensure that program leaders report out to them on program implementation, attaining goals, identifying trends and opportunities.

Development of the Organization’s Written Action Plan:

Organizations are required to develop a written action plan that describes how it will improve health care equity by addressing at least one of the health care disparities identified in its patient population.

Our observations have revealed that sometimes healthcare systems that incorporate a centralized healthcare equity program are able to demonstrate how they will improve health care equity from a system perspective but don’t address how disparities will be identified and addressed at the individual locations within the system.  This can apply to systems within a city/county region where healthcare disparities can vary greatly by zip code.  Keep in mind that if your organization holds its own Medicare billing number ( a/k/a CCN) then compliance with all of the standards must be demonstrated locally within that organization.  Only systems that function under one CCN may use system-level committees and initiatives to substantiate compliance.  We recommend that even if you meet the criteria of an integrated system, local periodic assessments should be conducted at each facility and that any relevant unique issues identified are addressed.  These should be incorporated into the system plan.

Additionally, in discussions with organizational and program leaders, they can often verbalize their target population for screening for health related social needs (HRSNs);  however, review of their written plan does not specify their process including defining the target population, which HRSNs that will be screened, when the patient population will be assessed and procedures for staff to follow when needs are identified.

Assessing for Health Related Social Needs:

Organizations are required to assess patients’ health-related social needs (HRSNs) and provide information about resources and support services available either internally or within the community.  The current standards have allowed organizations to limit this screening to small groups.  This allows for the organization to gain experience in the process before broadening the scope of the HRSN assessment.

Many organizations have implemented the screening with inpatient admissions or with ambulatory patients.  Several Electronic Medical Records (EMR) have now built in HRSN screening tools which makes the process easier but also opens the door to roll out broader screening for larger population groups.  Organizations with EMRs that do not have this feature or those with more paper-based healthcare documentation are challenged with the screening requirement.  This is especially true for aggregating screening data to determine population needs and other demographics that may help better focus activities and improvements with the health equity program.

Support of Patients with Identified Needs:

Once patients with HRSNs are identified, organizations are required to provide them with information on available resources.  Review of organizational practices on this requirement reveals that documentation related to the provision of available resource information is often inconsistent and often cannot be located within the medical record.  Therefore, it is difficult to assess if the organization is fully compliant in consistently providing information on community resources to patients with  identified HRSNs.  Occasionally, our team has made observations where patients may have required more extensive interventions based on their identified social needs;  however, the organization did not have an established policy/procedure on how these patients were defined and the process to be followed to engage with them.

We recommend organizations ensure they have in their written plan guidance on how information on community resources is to be provided to patients with identified HRSNs.  Also, we suggest this plan/policy include how patients with significant need/circumstances are identified and procedures to connect them in a timely manner to more intensive management (such as consultation with social workers, etc.).

Furthermore, we recommend organizations develop a means to measure data that patients with identified HRSNs are provided information on community resources.  This could include overall compliance with measurements on the method (Discharge Summary Education, Case Management Consults, Referral to Social Work, etc.)

The Use of Data:

Organizations are required to initiate actions when goals to improve health care equity are not reached or sustained.  This requires the organization to use data to evaluate progress.  We are noticing that written plans often do not include guidance on the use of data to evaluate performance.  For example, a review of an organization’s inpatient records revealed inconsistencies in compliance with screening all patients at time of admission for HRSNs (this organization decided that all inpatient admissions were to be screened for HRSNs).  Data indicated that the organization was 88% compliant in screening for HRSNs during a reporting quarter.  However, there was no goal set to establish a target or threshold for compliance nor documentation as to what actions the organization would take to improve.

Establishing key process measures or indicators can be of great value when taking on a large initiative such as Equity. Setting a process measure for each key component of the program will assist in identifying where the gaps exist or where the process is breaking down.  For instance, measuring on a temporary basis, the completion rate for the HRSN assessment may help to identify units, department or staff that need a little additional help. Part two of this series will provide additional information on establishing process and outcome measures and suggestions on how to display the data in a meaningful way.

Reporting Progress to Key Stakeholders:

At least annually, the hospital is required to inform key stakeholders about its progress to improve health care equity.  This includes Leaders, Licensed Practitioners and Staff.

Our team has observed that executive committee level minutes, including that of the Medical Staff, often are missing details regarding the organization’s progress with health care equity.  Often, this is a result of an organization without robust use of data that measures progress with their program.


Organizations should expect greater focus on health care equity over the next several years. Sound data mining, analysis, trending, and reporting are critical to ensuring that the program is effectively evaluated. Organizations should ensure that they are developing and honing these skills now, as there is always a possibility that the requirement for evaluating patient populations for disparities in care may be expanded.

For questions or to learn more contact the C&A team at 704-573-4535 or email us at

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