Measurement Strategies for The Joint Commission Health Care Disparities Standard: Defining Hospital-Based Requirements—Part 1

Abstract

More than 2 decades ago, the National Academies of Medicine (NAM; previously known as the Institute of Medicine) published a report exposing wide gaps in the quality of care and services received by people of color in the United States.1 Effective January 1, 2023, the Joint Commission’s (TJC) accredited hospital programs are required to meet new standards for leadership and performance that are designed to address health care disparities as a quality and safety priority. This current TJC Standard (LD.04.03.08) will be elevated to a National Patient Safety Goal (NPSG) in July 2023 and will be known as NPSG Goal 16: Improve health care equity (NPSG.16.01.01).2 Nurses in clinical settings face challenges in the assessment and measurement of health equity in everyday practice, in many cases due to complex situational and contextual factors beyond their reach. For example, the location for documentation of factors affecting health equity such as patients’ inability to pay for medications or secure transportation for follow-up are not readily accessible in the nursing flowsheets of electronic health records (EHRs).3 Similarly, social and economic barriers to care, known as health-related social needs (HRSNs),4 are often unrecorded or recorded on a problem list as “resolved” after a referral is made, when in fact, the referral itself is not necessarily a resolution.5 These barriers and others like them make health equity difficult to measure, monitor, and evaluate because many requisite data elements are missing or buried in nondiscrete documentation fields that are not easily searched or retrieved in the EHR.6To meet the challenges of providing equitable care for all patients—regardless of race, ethnicity, financial, educational or social status—advanced practice nurses, nurse scientists, and nurse leaders must consider how to assess, document, and design care delivery for all patients in a manner consistent with this National Patient Safety Goal (NPSG.16.01.01). To do so means clearly communicating not only what that goal is but also how to measure and where to document the factors associated with achieving the goal.The purpose of this column is to provide clarity around the definitions and measures of health equity and the specific elements of performance (EPs) that apply to nurses, nurse leaders, and nurse scientists in clinical practice settings. In the second part of this series, we will present case-based strategies for nurses to use in designing unit-based action plans and clinical inquiry projects to address improvements in health equity as defined by the NPSG.2The measurement of health equity poses several challenges for advanced practice nurses, nurse leaders, and nurse scientists in hospital settings. The first of these is the myriad definitions and terms used to classify the HRSNs of our patients and their families.4 Definitions have arguably been fluid over the past decade, reflecting the growing interest and commitment by national health care organizations to addressing these inequities. Most recently, a summary of key definitions was posted by the National Academies of Medicine, Culture of Health Program, with a disclaimer that terms reflect current understanding and are dependent on evolving evidence (Table).4 Because the definitions of health disparities, health equity, structural racism, and justice as they relate to accessible health services are so broad, a series of more measurable definitions is needed to operationalize clinical inquiry activities in the practice setting. By developing a set of operational definitions, nurses and others on the care team can identify and assess specific gaps and create action plans to continually improve disparities and shrink gaps in health equity.For nursing research and quality improvement (QI) teams, current definitions can be confusing because they are often used interchangeably or in error. One approach to disentangle the confusion is to communicate clearly and consistently what is being measured (definition), how (using which metric), when (frequency, shift, time of day), and by whom (manual entry or automated electronic capture) the data are being collected. By consistently providing feedback to staff on health equity measures according to levels of disparity, staff and other key stakeholders will quickly recognize not only their role in health equity improvement but also the value of the investment of time in achieving gains. In this series we will discuss health equity measures and their selection for clinical inquiry initiatives using the what, how, when, and by whom approach.As outlined in the Joint Commission R3 Report,5 a series of 6 performance measures is defined for leaders of hospitals and accredited health care entities. The rationale for each of these performance requirements is substantiated by the original NAM report.1 Additional evidence-based citations are included in this column to further explain the importance and value of making needed changes in the health care delivery system, measuring the extent to which those changes occur, and monitoring the ongoing impact of the changes. These 6 performance measures have direct implications for nursing and clinical inquiry.The first element of performance (EP 1) states that hospitals are required to designate a leader who will champion activities to reduce health disparities for patients served by the organization. Nurse leaders are in a key position to assume this role, as they are charged with defining, articulating, and disseminating the vision and creating the infrastructure to aid in implementation of that vision.The rationale offered in the report for this first performance requirement focuses on the ability of nurse leaders to set clear objectives, engage a team across key disciplines such as medicine and hospital finance, and promote quality improvement initiatives that are associated with clear lines of accountability and support.7,8 Advanced practice nurses and nurse scientists aid in the implementation of the vision through measurement activities, design of research and quality improvement projects, and mentorship of staff nurses carrying out those activities.The second element of performance (EP2) requires health care organizations to assess HRSNs of patients and document that assessment. Although the Centers for Medicare and Medicaid Services lists a broad array of HRSNs, the most common of these are access to transportation, ability to pay for prescriptions and medical care, literacy levels, and food or housing insecurity (Table).9The rationale for assessment of HRSNs is to increase the visibility of social needs that impact health, so that these might be included and addressed in the plan of care.10 Although health care practices, EHR capacity, and federal requirements are changing rapidly in this area, the current performance measure from TJC does not require assessment of HRSNs for every patient but for a “representative sample” of the population of interest.2The third requirement (EP3) is to identify gaps or inequities in care delivery, particularly inequities that disproportionately affect one group of patients more than another. The recommended approach for identification of health care disparities is through use of stratification of quality and safety data, however, use of this approach alone has well-recognized limitations.11,12The rationale for identifying disparities through stratification is to see existing, specific disparities more clearly and be better equipped to explore root causes more effectively.8,13 The use of hospital data sets is challenging for many reasons including differences in patient use of EHR portals (Figure 1), difficulty retrieving data entered by both patients and clinicians, the prevalence of missing data, and the likelihood that existing data may be misleading, such as incorrect data entry for race or ethnicity (Figure 2). Thus, stratification is only an initial step in identifying what differences and inequities exist. Subsequent measurement of contextual and process features such as differences in care process, procedure use, and special population-based differences is then needed to better understand root cause.The fourth requirement is to develop a written action plan for addressing at least one identified health care disparity at the local level. This requirement is a critical step in closing the gap on health care disparities and is dependent on the preceding requirements to accurately identify and respond to gaps using data analytics.The rationale for acting on observed disparities goes without saying, and yet, launching an actionable response to EP3 requires the dedication and investment of organizational leaders at several levels. Strategies for developing an action plan (EP 4) and acting on that plan (EP 5. Act on Low Performance in Achieving or Sustaining Goals), as well as disseminating progress reports based on the action plan (EP 6. Inform Key Stakeholders on Progress in Reducing Health Care Disparities) will be the focus of the next issue in this series.Together, these 6 elements of performance create an opportunity for hospitals to excel in resolving the national crisis of health inequity. As noted in the TJC standard, “an organization’s commitment to reducing health care disparities should be embedded throughout its culture and practices.”2 Fundamental processes embedded in the first 3 elements of performance for health equity standards include (1) identification of a nurse leader to champion the rollout and clinical investment in the effort, (2) implementation of a screening process for HRSNs as an integral part of the patient intake assessment, and (3) stratified reporting of key quality measures according to disparities (eg, central line–associated blood stream infections, catheter-associated urinary tract infections, hospital-acquired pressure injuries, discharge disposition, post-discharge follow-up appointment attendance, medication fill rates). Each of these fundamental processes is associated with complex, multifactorial challenges encompassing information technology, EHR platform support, staffing constraints, and the need to work together as multidisciplinary teams to achieve a broad plan of care for HRSNs that impact acute and critical care outcomes.A first step for enhancing health equity is improving everyday workflow for capturing measures of HRSNs. Doing so makes these measures more visible to care teams and more meaningful as the measures become connected to real people in the course of care delivery. As measures become part of usual documentation processes, they become an integral part of designing action plans for improving care delivery that result in improved health and reduced disparities.As reflected in the Table, common measures must be recorded accurately in discrete fields of the EHR to improve the reliability of reported disparities. One such measure often fraught with error is race and ethnicity. A primary concern about race and ethnicity documentation in EHR data sets is that the source of the data is often not the patient. For example, emergency department data stratified by race and ethnicity may capture race as reported by clinicians on an intake assessment rather than patient-reported race (Figure 2). When race and ethnicity are not self-reported, the margin of error in the data element rises incrementally.11 Although the process captured in this example is often unavoidable, particularly in acute or critical care settings, the likelihood of overestimating or underestimating representation of various racial and ethnic groups is high and should be acknowledged in the discussion of and integrated into the formulation of action plans.A second step toward improving health equity is providing nurses time to engage in critical thinking skills that contribute to achieving the broader goals of the vision. Successful strategies to capture data more accurately are dependent on the engagement of nurses across all levels of the organization but particularly those in direct care delivery roles, research and QI committee members, and unit-based champions. Mentors and nurses in these essential roles must appropriately integrate equity measures alongside other existing measures of quality when designing evidence-based QI initiatives and unit-based research. Nurses engaged in clinical inquiry are adept at designing clinical inquiry projects to address the long-familiar Institute of Medicine (now the National Academy of Medicine) landmark measures of quality, including safety, timeliness, effectiveness, efficiency, [equity], and person-centeredness (STEEEP).15,16 However, in our facile use of the STEEEP acronym for identification and selection of quality measures, the equity measure has been overlooked and undervalued until now. Central to effective achievement of institutional quality and safety goals is the broader humanitarian goal of providing not only higher quality care to all patients but providing that care equitably.Improving the accurate and reliable use of equity measures is dependent on supporting nurses in key roles responsible for documentation of health-related social needs. Consider the current workflow for documentation of social factors. What is being measured (definition), how (using which metric), when (frequency, shift, time of day), and by whom (manual entry or automated electronic capture) are the data are being collected? Who is responsible for the assessment and documentation of key social barriers, resources, and financial constraints? Often, input on these important contributors to health inequity fall solely to case managers or social workers, without the necessary input from direct care nurses. The role of frontline nurses and advanced practice nurses in assessment of these factors has not traditionally been a part of documentation workflow. As a result, the measures are not assessed for all patients in the same way and may only be evaluated in special cases, for example when a social worker is consulted.Inclusion of patient representatives from recognized groups affected by health disparities is also helpful and sometimes critical for improving the accuracy and reliability of hospital and health system–derived data that reflect disparities. Including advocates from representative, underserved, or relevant disadvantaged groups can better inform the processes and ultimate success of clinical inquiry initiatives.Nurse leaders are critical to articulating the vision for health equity and delivering the message of the value of nurses in realizing that vision for hospitals, health systems, and the communities we serve. At the local level, nurse leaders are uniquely positioned to support staff nurses’ understanding of the value of their individual contribution, that is, the daily, personal effort of nursing care and its alignment with organizational goals for equitable care delivery. By connecting unit-level clinical teams to the larger mission of the organization and national challenges, nurse leaders build a common understanding and recognition of the value of equity.17 Doing so enables them to then leverage that value to encourage specific patient population–level accountability to the measurement and reporting of equity-based improvement efforts.Collaborative efforts to address disparities in care across units, disciplines, and departments takes time.18 Nurse leaders are instrumental in building teams of shared decision-makers who understand the key components of action plans and clinical inquiry projects that reflect equitable care delivery. Investing in this team-based understanding of health equity as part of the work culture directly affects achievement of national patient safety goals and requires organizational effort and commitment.19The greatest value of implementing a health equity framework is improving patient care delivery and reducing disparities that result from longstanding, underlying structural inequities in our society.4 As nurse leaders and scientists, we can design changes in care delivery systems that mitigate disparities, such as inequitable discharge disposition or discharge without access to medications, adequate food, or housing (Table). However, without a vision and a framework for measurement and reporting on key driving factors associated with these disparities, change in the fundamental reasons for health care disparities will not occur. This driving force is the foundation of the National Patient Safety Goal 16.0 and the underlying rationale behind changes in accreditation requirements from TJC2 and designation by national nurse-led organizations such as Magnet.20 Achieving TJC accreditation or Magnet designation challenges organizations to understand and invest in the direct and indirect costs associated with hard-wiring the infrastructure needed to implement a health equity framework.21,22 These costs include but are not limited to expanding budgets for development of EHR documentation platforms, investing in nurse training and skills development for improved assessment of social determinants of health, and elevating the dissemination of reports on local health system–based disparities to actionable levels, both above nursing leadership and below, to the front-line staff who are in key positions to make changes a reality and a success for patients.The Magnet vision as it relates to health care disparities is centered on flexibility, discovery, and innovation.23 Implementing each of the model components takes visionary leadership on the part of nurse leaders and time, talent, and tenacity on the part of managers and frontline staff to get the work done on a daily basis. In the context of pressing patient, staffing, and health system management demands, these commitments become even more challenging. In the second part of this series, we will present case examples describing how various organizations have operationalized a health equity framework to address disparities in care and to take on underlying structural racism in the communities and neighborhoods served.24 These strategies are examples of how the Magnet vision can be operationalized to address HRSNs of patients across the Forces of Magnetism, particularly as these efforts pertain to Professional Models of Care, Quality of Care, and Quality Improvement (Forces 5, 6, and 7). As nurse leaders continue to develop innovative staffing models, promote frontline staff to address HRSNs, and allocate staff time to work on clinical inquiry projects supporting equity in care delivery, we will achieve a work culture that is aware and responsive to local structural inequities.As health care systems around the United States design and implement new infrastructure and models of care to address health equity as defined by NPSG 16.0, clinical inquiry supports these evolving efforts. This column has focused on providing clarification around the definitions and measures of health equity and the specific EPs affecting nurses and nurse scientists in clinical practice settings. In the second part of this series, we will present case-based strategies for nurses to use in designing action plans and unit-based clinical inquiry projects that address local HRSNs and lead to improvements in disparities at the hospital and unit levels.