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R3 Report Issue 38: National Patient Safety Goal to Improve Health Care Equity

National Patient Safety Goal to Improve Health Care Equity

Effective July 1, 2023, Standard LD.04.03.08, which addresses health care disparities as a quality and safety priority, will be elevated to a new National Patient Safety Goal (NPSG), Goal 16: Improve health care equity, and moved to NPSG.16.01.01 for ambulatory health care organizations, behavioral health care and human services organizations, critical access hospitals, and hospitals. The NPSG standard and 6 elements of performance (EPs) increases the focus on improving health care equity as a quality and safety priority, but the requirements for accredited organizations are not changing. While some of the original language from Standard LD.04.03.08 and its EPs were revised to focus on improving health care equity rather than reducing health care disparities, the intent behind the standard and associated EPs remains the same. Organizations will still be required to do the following:

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

As with the original requirement, NPSG16.01.01 will apply to the following Joint Commission–accredited organizations:

  • All critical access hospitals and hospitals
  • Ambulatory health care organizations providing primary care within the “Medical Centers” service in the ambulatory health care program (the requirements are not applicable to organizations providing episodic care, dental services, or surgical services)
  • Behavioral health care and human services organizations providing “Addictions Services,” “Eating Disorders Treatment,” “Intellectual Disabilities/Developmental Delays,” “Mental Health Services,” and “Primary Physical Health Care” services

The prepublication version of the requirements to improve health care equity will be available online until June 30, 2023. After July 1, 2023, please access the new requirements in the E-dition or standards manual.

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