The Joint Commission, one of the leading accrediting organizations of health care entities, recently announced significant updates to require that health care organizations invest in their health equity promotion infrastructure and The Joint Commission’s intention to acknowledge those organizations with more robust health equity initiatives and programs.

Effective January 1, 2023, The Joint Commission implemented new and revised standards for hospitals, ambulatory health care organizations, and behavioral health care organizations aimed at reducing health care disparities.

Most significantly, The Joint Commission added a new standard, LD.04.03.08, to the Leadership (LD) chapter. This standard provides: “Reducing health care disparities for the [organization’s] [patients] is a quality and safety priority.”[1] The new standard, which applies to all hospitals and certain ambulatory health care organizations and behavioral health care organizations, has the following six elements of performance:

  1. The [organization] designates an individual(s) to lead activities to reduce health care disparities for the [organization's] [patients].
  2. The [organization] assess the [patient's] health-related social needs and provides information about community resources and support services.
  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].
  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.
  5. The [organization] acts when it does not achieve or sustain the goal(s) in its action plan to reduce health care disparities.
  6. At least annually, the [organization] informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce identified health care disparities.

Explaining the purpose of these requirements, The Joint Commission states:

Although health care disparities are often viewed through the lens of social injustice, they are first and foremost a quality of care problem. Like medication errors, health care–acquired infections, and falls, health care disparities must be examined, the root causes understood, and the causes addressed with targeted interventions. Hospitals need established leaders and standardized structures and processes in place to detect and address health care disparities. These efforts should be fully integrated with existing quality improvement activities within the hospital, such as activities related to infection prevention and control, antibiotic stewardship, and workplace violence.

Effective July 1, 2023, The Joint Commission will elevate this new standard to a National Patient Safety Goal (NPSG). The requirements will remain exactly as provided in LD.04.03.08, but will be reorganized as NPSG 16.01.01 in order to “increase the focus on improving healthcare equity versus reducing healthcare disparities.”

Additional changes related to health equity made by The Joint Commission include revisions to and broader application of standards in the Record of Care, Treatments, and Services (RC) and the Rights and Responsibilities of the Individual (RI) chapters to require that medical records contain a patient’s race and ethnicity and to prohibit discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

The Joint Commission also announced the creation of a new, voluntary certification program in Health Care Equity. The certification will initially only be available to hospitals and critical access hospitals. A pre-application is currently available on The Joint Commission’s website for interested hospitals with the full application to be available in July 2023.

Accredited hospitals, ambulatory health care organizations, and behavioral health care organizations subject to these new standards must ensure they address these requirements as part of their accreditation compliance.  While the elements of performance are intended to provide flexibility in how entities approach these issues, the standards make health care equity an addressable quality issue requiring affirmative steps be taken to maintain their accreditation status with The Joint Commission.


[1] The bracketed words in the excerpted language of The Joint Commission standards and elements of performance vary slightly between types of accredited entities. For example, the term “patient” is used in the standards for hospitals while the term “individual served” is used in standards for behavioral health care organizations.

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