This is part four of our series on the Five Mechanisms of External Accountability for Health Equity. Read parts one, two, three, and five. 

Part 4: Compliance

No organization can be the sole arbiter of its own progress, especially when it comes to issues of equity and justice. Its progress must also be gauged and monitored by reliable external stakeholders. This idea of compliance is not a new one in health care, yet most existing compliance mechanisms don’t currently extend to health equity performance. Changing this is a critical step to ensuring healthcare institutions are held accountable for their health equity performance.

To make this a reality, the bar must be raised for both the internal and external standards healthcare systems must meet. And their progress toward these standards must be actively assessed and monitored by different local, state, and federal mechanisms. Compliance is the fourth of the Five Mechanisms of External Accountability for Health Equity (see image below) examined in this blog series, and it is explored in-depth in this post.

What Compliance Looks Like in Practice

While most common mechanisms of institutional accountability in health care—reports, surveys, disclosures, program evaluations, and accreditation—serve a compliance purpose, they often fall short on equity. Current national compliance mechanisms make it hard for stakeholders to get institution-level insights on health equity performance. For example, The Joint Commission—the nation’s oldest and largest accrediting body in health care—only recently identified if hospitals collect race and ethnicity information. Even then, it did not ask hospitals if or how that data is examined alongside care access and outcomes data, nor if that data is used to demonstrate improvements in health equity. This has finally started to shift. In June 2022, The Joint Commission published new accreditation requirements for providers, which now include:

• Designating a leader or leaders to direct activities to reduce healthcare disparities within an organization;
• Assessing patients’ health-related social needs and providing information about community resources and support services;
• Identifying healthcare disparities in the patient population by stratifying quality and safety data using socio-demographic characteristics;
• Developing a written action plan that describes how the organization will address at least one of the healthcare disparities identified in its patient population; and
• Taking action when the goals in its plan to reduce health disparities are not achieved or sustained.

(Of note, The Joint Commission cited HealthBegins’ STEPS Forward module as one underpinning of these new and revised requirements.). 

While this is a step in the right direction, current compliance mechanisms across the industry do not yet go far enough in holding institutions accountable for making their health equity performance data available and accessible for public scrutiny. The examples below demonstrate progress and provide ideas from other sectors that could be helpful if modified and applied to health care.

Tools for internal assessment and monitoring

The National Committee for Quality Assurance recently launched a new Health Equity Accreditation, which provides a framework for healthcare organizations to achieve health equity goals and a survey tool to help them self-assess and prepare for accreditation. This new accreditation standard is a welcome sign of progress, and it represents an opportunity to go further; healthcare organizations could be required to demonstrate progress in making their health equity-related data and decision-making accessible to impacted patients and communities.

Similarly, the Health Equity Organizational Assessment was created in 2018 by the Health Quality Innovation Network to help healthcare institutions prioritize health equity. The free self-assessment allows institutions to examine their culture and practices around equity across seven areas that span from collecting data to communicating findings to resolving gaps in care. While the assessment creates some benchmarks for health equity, institutions that complete it are left to make and enforce changes on their own, and the assessment data is not easily accessible to community members or external stakeholders.

Possibilities for external monitoring

Health care can look to other sectors for strong examples of external monitoring. For example, many U.S. cities and counties have passed ordinances to create benchmarking and transparency requirements for energy efficiency in existing buildings. Cities like Seattle have even adopted an equity approach for this work by prioritizing outreach and compliance for buildings that are in BIPOC and marginalized communities. Similar types of benchmarking ordinances could be adopted to mandate health equity standards for health care. This might involve building on policy benchmarks created by initiatives like CityHealth, which evaluates cities based on how well their policies promote health and well-being. City governments can create new policy benchmarks that mandate health equity reporting standards and transparency for local hospitals and health systems.

Questions* You Should Ask About Compliance at Your Healthcare Institution

*These questions are adapted from Dr. Bram Wispelwey and Dr. Michelle Morse’s article, An Antiracist Agenda for Medicine.

To monitor data about health equity efforts, HealthBegins recommends finding opportunities to ask and discuss these questions about compliance at your healthcare institution:

1. What internal monitoring and evaluation processes does your healthcare institution use to ensure that health equity initiatives are effectively implemented and generating positive outcomes?
2. To what extent does your institution’s board provide oversight and monitor institutional efforts to advance racial justice and health equity, including efforts to address institutional, social, and structural drivers of health equity?
3. What external monitoring and evaluation processes—both local and national—does your healthcare institution actively participate in to help ensure health equity initiatives are effectively implemented and generating positive outcomes?
4. To what extent are patients and community members, including those with lived experience and belonging to marginalized communities, involved in monitoring and evaluation processes?
5. What are your healthcare institution’s benchmarks, agreed to with the community, for measuring compliance with advancing racial justice and health equity?
6. Beyond reporting on equity-related measures required by payers and regulators, how else does your healthcare institution engage in adaptive learning and seek and share information with internal and external stakeholders to help achieve long-term health equity and racial justice goals?

By: Rishi Manchanda, Sadena Thevarajah, and Kate Marple