Healthcare equity standard now NPSG

Effective July 1, 2023, Leadership (LD) Standard LD.04.03.08 — which addresses healthcare disparities as a quality and safety priority — will be elevated to a new National Patient Safety Goal^® (NPSG^®) for:

• Hospitals
• Critical access hospitals
• Ambulatory care organizations that provide primary care within the Medical Centers service in the ambulatory care program
• Behavioral healthcare and human services organizations that provide
  • Addictions services
  • Eating disorders treatment
  • Intellectual disabilities/developmental delays
  • Mental health services
  • Primary physical healthcare

This change is being made to increase the focus on improving healthcare equity versus reducing healthcare disparities — but the requirements for accredited organizations are not changing. The intent behind the standard and associated elements of performance remains the same; however, they are now stated as NPSG Goal 16. Organizations will still be required to do the following:

• Identify an individual to lead activities to improve healthcare equity.
• Assess patients’ health-related social needs.
• Analyze quality and safety data to identify disparities.
• Develop an action plan to improve healthcare equity.
• Act when the organization does not meet the goals in its action plan.
• Inform key stakeholders about progress to improve healthcare equity.

Following the implementation of NPSG Goal 16, Standard LD.04.03.08 will be deleted. Additionally, the resources in The Joint Commission’s Health Care Equity Accreditation Standards and Resource Center will continue to apply to the new NPSG. The resources contain valuable information for organizations working toward compliance with the healthcare equity requirements.

View the prepublication standards. For questions regarding NPSG Goal 16, contact the Department of Standards and Survey Methods.