A New Accreditation Standard and What It Means for Medical Staffs
A New Accreditation Standard and What It Means for Medical Staffs

It’s no secret that patients from marginalized groups experience lower quality health care.  Acknowledging its role in closing the health care disparity gap, the Joint Commission recently announced new and revised requirements to reduce health care disparities in accredited facilities.  For medical staffs, the new accreditation standard provides an opportunity to lead the fight against health care disparities.

Medical literature over the past twenty years confirms the persistence of health care disparities.  In August 2021, the Journal of the American Medical Association devoted an entire issue to disparities in medicine.  Data also confirms that, despite progress in areas like access to care, health care disparities remain among patient groups that have historically suffered discrimination or exclusion based on race, ethnicity, socio-economic status, class, sexual orientation, gender identity, age, geographic location, education, and disabilities. 

With this background, the Joint Commission set out to develop new and revised standards to improve health care equity.  Concluding this process earlier this summer, the Joint Commission announced that, effective January 1, 2023, accredited facilities must comply with Standard LD.04.03.08, a new standard in the Leadership (LD) chapter with 6 new elements of performance (EPs).  As relevant here, the new standard will require hospitals to:

  • Identify individuals to lead activities to reduce health care disparities;
  • Assess patients’ health-related social needs and provide information about community resources and support services;
  • Identify health care disparities in its patient population by stratifying quality and safety data using the sociodemographic characteristics of the hospital’s patients;
  • Develop a written action plan that describes how it will address at least one of the health care disparities identified in its patient population;
  • Act when it does not achieve or sustain the goals in its action plan; and
  • Inform key stakeholders—including leaders, licensed practitioners, and staff—about its progress to reduce identified health care disparities.

In hospital settings, physician leaders who run the organized medical staff are expected to play an important role in implementing these new requirements, and for good reason.  The Joint Commission acknowledges that physician leadership has been consistently linked to successful quality improvement projects at hospitals.  As the clinical boots on the ground, medical staff members and other licensed practitioners are uniquely positioned to collect information from and provide health care services to patients.  Moreover, medical staffs already have in place structures and processes to provide continuing education courses to physicians.  Finally, addressing health care disparities requires collaboration with all stakeholders in any given health system, and medical staffs are experienced in working closely with hospital leadership on a host of quality care issues. 

Medical staffs can take a number of proactive steps to ensure compliance with the new Joint Commission standards, including:

  • Review and, if necessary, update medical staff bylaws to reaffirm the medical staff’s commitment to reducing health care disparities.
  • Form a subcommittee or create a medical staff position responsible for leading activities to reduce health care disparities and coordinating with other hospital leaders on health equity initiatives.
  • Educate medical staff members about unconscious bias and the impact it can have on patient outcomes.

As the self-governing body for licensed practitioners at hospitals, medical staffs now have the unambiguous responsibility of improving health equity.  Medical staff leadership and administration should consult with outside counsel to develop strategies to ensure compliance with Joint Commission standards and help close the gap of disparate patient outcomes for historically marginalized groups.    

  • Michael  Gawley

    Michael Gawley is co-chair of Nossaman's Healthcare Group. He specializes in advising health systems, hospitals, medical staffs and large medical groups on a wide range of credentialing, peer review and patient safety topics ...

Our Health Law Ticker is a one-stop resource for everything new and noteworthy medical staffs and peer review. We cover recent developments in healthcare legislation, litigation, regulatory compliance, HIPAA, peer review, medical staffs and general operations for healthcare delivery systems.

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