Issue 36, June 20, 2022
Page | 3
© 2022 The Joint Commission
References:*
1. Smedley, B., Stith, A., & Nelson, A. (2003). Unequal treatment: confronting racial and ethnic disparities in health
care. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health
Care. Washington, D.C.: National Academy Press.
2. Gottlieb, L., Wing, H., & Adler, N. (2017). A systematic review of interventions on patients’ social and economic
needs. American Journal of Preventive Medicine. 53(5): p. 719–729. doi: 10.1016/j.amepre.2017.05.011
3. Tipirneni, R. (2021). A data-informed approach to targeting social determinants of health as the root causes of
COVID-19 disparities. American Journal of Public Health. 111, 620_622.
doi: 10.2105/AJPH.2020.306085
4. Ogunwole, S. & Golden, S. (2021). Social determinants of health and structural inequities—Root causes of
diabetes disparities. Diabetes Care. 44 (1): 11–13. doi: 10.2337/dci20-0060
5. Crear-Perry, J., Correa-de-Araujo, R., Johnson, T., McLemore, M., Neilson, E, & Wallace, M. (2021). Social and
structural determinants of health inequities in maternal health. Journal of Women's Health. 30(2):230-235. doi:
10.1089/jwh.2020.8882
*Not a complete literature review.
Requirement
EP 1: The [organization] designates an individual(s) to lead activities to reduce health care disparities for the
[organization’s] [patients].
Note: Leading the [organization’s] activities to reduce health care disparities may be an individual’s primary role or
part of a broader set of responsibilities.
Rationale
Leadership is an essential component of quality improvement activities. “Beyond any specific set of leader
behaviors, team clarity regarding leadership is associated with clear team objectives, higher levels of engagement to
promote excellence and greater innovation.”
6
Management-level leadership, physician leadership and team
leadership have been consistently associated with successful quality improvement projects, and the lack of such
leadership is frequently linked to the failure of quality improvement efforts. Identifying an individual to lead the
organization’s activities to reduce health care disparities establishes clear lines of accountability and ensures that
staff have the support necessary to implement successful initiatives. Multiple organizations and individual experts
recommend having a designated leader for health care equity efforts.
7-13
References:*
6. O'Donovan, R., Rogers, L., Khurshid, Z., De Brún, A., Nicholson, E., O'Shea, M., Ward, M., & McAuliffe, E.
(2021). A systematic review exploring the impact of focal leader behaviours on health care team
performance. Journal of Nursing Management. 29(6): 1420-1443.
7. Kaplan, H., Brady, P., Dritz, M., Hooper, D., Linam, W., Froehle, C., & Margolis P. (2010). The influence of
context on quality improvement success in health care: A systematic review of the literature. Milbank
Quarterly. 88(4):500-599. doi: 10.1111/j.1468-0009.2010.00611.x
8. Centers for Medicare & Medicaid Services. (2022). Building an organizational response to health disparities.
https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Health-Disparities-Guide.pdf
9. O’Kane, M., Agrawal S., Binder, L., Dzau, V., Gandhi, T., Harrington, R., Mate, K., McGann, P., Meyers, D.,
Rosen, P., Schreiber, M., & Schummers, D. (2021). An equity agenda for the field of health care quality
improvement. NAM Perspectives. National Academy of Medicine. Washington, DC. doi: 10.31478/202109b
10. Manchanda, R., Brown, M., Cummings, D. (2022). Racial and health equity concrete STEPS for health
systems. Translate your commitment to racial and health equity into action in your health system. American
Medical Association STEPS forward. https://edhub.ama-assn.org/steps-forward/module/2788862
11. Chin, M., Clarke, A., Nocon, R., Casey, A., Goddu, A., Keesecker, N., & Cook, S. (2012). A roadmap and best
practices for organizations to reduce racial and ethnic disparities in health care. Journal of General Internal
Medicine, 27(8), 992–1000. doi: 10.1007/s11606-012-2082-9
12. Davis, L., Martin, L., Fremont, A., Weech-Maldonado, R., Williams, M., & Kim, A. (2018). Development of a
long-term evaluation framework for the national standards for culturally and linguistically appropriate
services (CLAS) in health and health care. Office of Minority Health & Centers for Medicare & Medicaid
Services.
https://www.minorityhealth.hhs.gov/assets/PDF/Natn_CLAS_Standards_Evaluation_Framework_Report_PR
-3598_final_508_Compliant.pdf