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.
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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.
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):
In TJC’s R3 Report on the new requirements, TJC makes 3 key points that immediately let you know they’re on your side:
Now, let’s look at each of the EPs and how you can make them work for you...
| EP1: The organization designates an individual(s) to lead activities to reduce health care disparities for the organization’s patients. |
| EP2: The organization assesses the patient’s health-related social needs (HRSNs) and provides information about community resources and support services. |
| 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. |
| 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. |
| EP5: The organization acts when it does not achieve or sustain the goal(s) in its action plan to reduce health disparities. |
| EP6: At least annually, the organization informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to reduce health care disparities. |
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:
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.”
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.
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 HelpAlong 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.
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