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A Guide to The Joint Commission’s New Health Equity Requirements

TJC’s new health equity standard LD.04.03.08 is surprisingly flexible. Here’s everything you need to get started without breaking a sweat.

When The Joint Commission (TJC) released its new requirements to reduce health care disparities (Standard LD.04.03.08), it’s perfectly natural if your first response was to feel frustration. “Yes, we desperately want to achieve health equity,” you probably told yourself. “But all these requirements are stacking up and it's a lot!”

Here’s the good news: TJC totally gets that. Yes, the requirements are mandatory. But they are also very, very forgiving. In fact, upon closer inspection, they’re actually an incredibly helpful roadmap for how to get a successful health equity initiative off the ground.

So, take a good breath and let's walk through TJC’s new, flexible health equity accreditation requirements and how you can actually make them work to your advantage.

What Is Standard LD.04.03.08?

Standard LD.04.03.08: Reducing health care disparities for the organization’s patients is a quality and safety priority.

In 2022, TJC announced that they would be including a health equity component as part of its accreditation requirements for healthcare organizations, including hospitals that are accredited through TJC’s ORYX® quality improvement initiative. Standard LD.04.03.08, which you’ll notice is a Leadership (LD) requirement (more on that below), is them making good on that promise.

The standard is broken down into 6 very flexible elements of performance (EPs), which you will have to demonstrate in order to meet the standard. We’ll walk you through each of those EPs in just a moment.

Does Standard LD.04.03.08 Apply to Me?

Most likely, yes. While TJC has woven health equity thinking into previous requirements, this is a focused effort to make health equity its own dedicated priority. As such, Standard LD.04.03.08 will apply to the following (click here for the detailed list):

  • All hospitals
  • All critical access hospitals
  • Ambulatory health care organizations that provide primary care (except those providing episodic care, dental services, or surgical services)
  • Most behavioral health care and human services organizations 

How It’s Designed to Help (not Hurt) You

In TJC’s R3 Report on the new requirements, TJC makes 3 key points that immediately let you know they’re on your side:

  1. First, if we are to achieve real change, we must treat health equity no differently than infection prevention and control or antibiotic stewardship. That means implementing structures, processes, standards, and measures – a SYSTEM—for health equity. These requirements are designed to help you start building that system.
  2. Secondly, these requirements are flexibly designed to accommodate organizations at any stage of their health equity journey—even those just getting started—because, as TJC admits, no one in the industry has truly figured out how to “effectively and efficiently” achieve health equity just yet.
  3. Lastly, these requirements were strategically placed in the Leadership chapter because health equity is first and foremost a leadership issue. The only way any of us can succeed is if our C-suite, physician leaders, and board of directors are all fully committed to the process.

Now, let’s look at each of the EPs and how you can make them work for you...

EP1: Assign a Leader (or Leaders!)

EP1: The organization designates an individual(s) to lead activities to reduce health care disparities for the organization’s patients.
EP1 Rationale

Data shows that leadership is linked to successful quality improvement projects, while the lack of leadership is often cited as the reason why other quality improvement efforts fail. Because TJC sees health equity as a quality-of-care issue, it wants to follow the data and make sure you’ve got someone calling the shots and getting things done.

Why It's So Flexible

You don’t have to hire a new person, create a new job title, or put all the weight of the initiative on one person’s shoulders. TJC doesn’t care how you fill the leadership role(s) as long as you’ve got someone minding the ship.


EP2: Assess & Treat a Sample of Patients

EP2: The organization assesses the patient’s health-related social needs (HRSNs) and provides information about community resources and support services.
EP2 Rationale

This one’s not rocket science. Identifying HRSNs and then delivering the right interventions is proven to lead to improvements in health outcomes, process measures such as medication adherence, and utilization rates such as hospital re-admissions.

One thing worth noting is that TJC uses the term health-related social needs (HRSN) instead of social determinants of health (SDOH) “to emphasize that HRSNs are a proximate cause of poor health outcomes for individual patients, as opposed to SDOH, which is a term better suited for describing populations.”

Why It's So Flexible

The standard does not demand that you screen all patients. A sampling is all that’s required. And how you build your sample is up to you. For example, you could decide it makes sense for you to start off by assessing just a high-risk population, such as those with diabetes or pregnant women.

Another Reason It's So Flexible

You also get to decide which social needs you assess. TJC provides a starter list (see below). But if, for example, assessing for food and housing insecurities is most practical for your organization right now, you’re free to focus on only those. Just remember that, in order to meet the standard, you have to be able to follow through with some form of intervention, so that may dictate which HRSNs you choose.

Examples of HRSNs

  • Access to transportation
  • Difficulty paying for prescriptions or medical bills
  • Education& literacy
  • Food insecurity
  • Housing insecurity


EP3: Stratify (Some of) Your Data

EP3: 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.
EP3 Rationale

Stratifying your data allows you to clearly identify disparities that are hiding in plain sight. Then you can start to do the real work: uncovering the root causes for the disparities and developing action plans to address them. We also suspect that stratified data will be a requirement of many new quality and safety measures moving forward, so this is a “you-have-to-start-somewhere” move.

Why It's So Flexible

You get to choose what data you want to stratify. Perhaps you want to focus on well-known areas of concern, like maternal care or diabetes management. Or maybe it makes more sense for your organization to look at data that affects all patients, such as experience of care and communication.

Another Reason It's So Flexible

You also get to choose how you want to stratify your data. TJC has provided some suggested sociodemographic characteristics to start with (see below), but it’s ultimately up to you. It should be noted that collection of patient race and ethnicity data is now required under TJC’s new Record of Care, Treatment, and Services (RC) requirement (see further below), so you will probably want to include that in your starter stratification plan.

Examples of
Sociodemographic Characteristics

  • Age
  • Gender
  • Preferred language
  • Race & ethnicity


EP4: Write an Action Plan

EP4: 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.
EP4 Rationale

You can’t get where you’re going without a roadmap. This EP forces you to sit down with your different departments to coordinate, plan, and document how you’re going to measurably improve.

Why It's So Flexible

The key phrase here is “at least one.” That’s all they’re asking you to do: focus on one disparity and build a plan around it. To meet the standard, your plan should clearly define the following:

  • The health disparity
  • The patient population of focus
  • Your target goal for improvement
  • What strategies and resources you’ll need
  • A system for monitoring and reporting your progress


EP5: Course-Correct As Needed

EP5: The organization acts when it does not achieve or sustain the goal(s) in its action plan to reduce health disparities.
EP5 Rationale

Your action plan needs to be more than a box you check off on your requirements to-do list. This EP is designed to make sure you’re reviewing the metrics regularly, collecting feedback from your patients and staff, and evaluating your workflow and training to continually move the ball toward your goal line.

Why It's So Flexible

What TJC is clearly saying is that it’s ok to fail. Failing is part of progress—provided you learn from your failure and apply what you learn moving forward. Also, keep in mind that your action plan can focus on just one disparity to start with, so you have total control over how many goals you have to track and optimize for.


EP6: Communicate Your Progress

EP6: At least annually, the organization informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce health care disparities.
EP6 Rationale

As a quality leader, you know that real change requires a complete culture shift. The organization has to live and breathe it. Regular communication and progress updates should be focused not only on conveying information, but developing a fervent fan base that’s as passionate about health equity as you are.

Why It's So Flexible

You’re only required to deliver one progress update a year. Maybe you conduct a system-wide Health Equity Summit. Some health care systems publish Health Equity Annual Reports. Or maybe more frequent—and less formal—communication is your team’s preferred style. How you deliver the latest news on health equity is totally up to you.


Additional Requirements: Race & Ethnicity Data Collection

TJC’s requirement to collect race and ethnicity data within a patient’s medical record has historically only applied to acute-care hospitals (Standard RC.02.01.01, EP 25). For 2023, this requirement will now extend to following:

  • Critical Access Hospitals: Standard RC.02.01.01, EP25
  • Ambulatory: RC.02.01.01, EP31
  • Behavioral Health Care and Human Services: RC.01.01.01, EP26

Additional Requirements: Prohibiting Discrimination

Similarly, the Rights & Responsibilities of the Individual (RI) standard that prohibits discriminatory practices in acute-care hospitals (Standard RI.01.01.01, EP29) now applies to ambulatory practices, behavioral health and human services organizations, and critical-access hospitals. The standard states that your organization “prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.”

Don’t Miss TJC’s Free Tools

You’ve gotta give it to them: TJC really is doing everything in its power to make LD.04.03.08 easy for your team to understand and implement. Case in point: their incredible Health Equity Resource Center, which has free tools, templates, guides, and case studies for each of the 6 EPs, as well as their free on-demand webinar that highlights some of the center’s best tools.

For all you go-getters, TJC is also actively developing a new Health Equity Certification program that you can apply for now. Certification is estimated to take 9-12 months and can be a powerful way to position your organization as a national leader in health equity.

Be the First to See Medisolv’s NEW Equitable Care Module

Like TJC, Medisolv is also doing everything we can to make your health equity journey a breeze. Register now for our FREE webinar to learn more about our ENCOR platform’s new Equitable Care Module, which lets you stratify your data and fulfill today’s health equity measure requirements with unprecedented speed. Or check out these additional resources from our Education Center:


Medisolv Can Help 

Along with award-winning software, each client receives a dedicated Clinical Quality Advisor that helps you with your technical and clinical needs.

We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.

  • We help troubleshoot technical and clinical issues to improve your measures.
  • We keep you on track for your submission deadlines and ensure you don’t miss critical dates.
  • We help you select and set up measures that make sense based on your organization's situation.
  • You receive one advisor that you can call anytime with questions or concerns - no limit on hours.

Contact us today.





Erin Heilman

Erin Heilman is the Vice President of Marketing for Medisolv, Inc.

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