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The Joint Commission Establishes Certification to Reflect Hospitals' Dedication to Equitable Care

Effective July 1, 2023, The Joint Commission (TJC) is accepting applications from eligible hospitals and hospital systems for its Health Care Equity (HCE) Certification program. By way of background, TJC generally accredits hospitals and other health care organizations that meet certain standards for quality improvement and patient safety. Accreditation is awarded to organizations that maintain compliance with TJC standards and demonstrate a commitment to continuous improvement in patient care. The newly implemented HCE Certification program specifically evaluates a health care entity's commitment to equitable patient care in addition to maintaining the health care standards required for TJC accreditation. Through the HCE Certification program, TJC seeks to promote higher standards of health equity across the United States by guiding hospitals in the reduction of health disparities.

TJC defines health equity as "providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status." The HCE Certification program is voluntary and recognizes the efforts of various organizations in providing equitable care, treatment, and services within their respective communities. Applications for the HCE program are available for all TJC-accredited hospitals and non-TJC-accredited hospitals that comply with applicable federal laws, including the Medicare Conditions of Participation. While this program is currently only available for hospitals and hospital systems, TJC aims to create standards specific to other health care settings in the future.

The HCE Certification program is broken down into five domains established by TJC, each of which has its own guidelines for the applicant organization that will be reviewed by TJC. These domains include Leadership, Collaboration, Data Collection, Provision of Care, and Performance Improvement, as follows:

  1. Leadership: Established by a showing that health care equity is a priority for the organization; the organization has identified goals for reducing health care disparities listed within its organizational strategic plan to provide equitable care. The Board of the organization is actively involved in the review and approval process for the strategic plan.
  2. Collaboration: Established through organizational collaboration with patients and community members to identify patient and community-level needs that must be addressed to improve health care equity.
  3. Data Collection: Met via the organization's review of data collected through patient self-reported surveys, needs assessments, and staff interviews to identify opportunities to improve health care equity within the community it serves.
  4. Provision of Care: Achieved through the organization's support of workforce diversity, provision of adequate staff training to ensure equitable care, effective communication with patients, accommodation of the needs of patients with disabilities, and addressing of the health-related social needs of its patients.
  5. Performance Improvement: Established via the organization's annual analysis of its data and stratification of at least three quality and/or safety measures for priority clinical conditions using the sociodemographic characteristics of its patients. The organization uses this data to identify opportunities to address health care disparities and improve diversity and inclusion efforts for its staff.

If an eligible hospital satisfies the requirements for each of the above domains, it will receive a badge certification showcasing its commitment to health equity excellence. TJC expects that many of its accredited hospitals will face minimal challenges in meeting the standards for the certification. HCE-certified hospitals and hospital systems that maintain equitable health care standards based upon the TJC criteria also demonstrate a willingness to work with impacted communities to address health-related social needs to reduce health disparities.

Interested hospitals are encouraged to submit applications for the HCE Certification program as soon as possible to be scheduled for their review. Baker Donelson's Health Systems and Hospitals Practice Group and the Health Care Discrimination Litigation and Compliance Practice Group stand equipped to guide interested hospitals and hospital systems through the application process. If you have any questions about this alert, please contact Stefanie Doyle, Michelle Williams, Melodie Hengerer, or the Baker Donelson Health Law team member with whom you regularly work.

Kennedy Hagens, a clerk at Baker Donelson, contributed to this alert.

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