New National Patient Safety Goal to Improve Health Care Equity

Nikki Roettger, CPHQ, Director of Continuous Compliance
February 9, 2023 by
Simplifyance, Gina Thorne

New Joint Commission standard, LD.04.03.08 requires accredited organizations to address healthcare disparities as a quality and safety priority for ambulatory healthcare organizations, behavioral healthcare, and human services organizations, critical access hospitals, and hospitals. The new standard became effective on January 1, 2023.

On July 1, 2023, this new standard is being elevated to the newest National Patient Safety Goal NPSG.16.01.01: Improve health care equity. The requirements themselves will not change; the change is being made to highlight the importance of addressing disparities as a quality priority

Healthcare disparities have been recognized as a quality of care issue in healthcare for almost twenty years. Studying and consistently addressing root causes for these disparities through standardized processes and structures will help to improve care for affected populations (racial and ethnic minorities, women, older adults, people with disabilities, and other marginalized groups). This work must be integrated with other organizational quality improvements priorities such as infection prevention and control, and workplace violence.

Health-related social needs (HRSN) are frequently identified as root causes of outcomes disparities at the individual level (as contrasted with social determinants of health, which typically describe populations). Routinely screening for and considering how to address HRSNs in a representative sample of clients will likely be foundational to early healthcare equity efforts as healthcare providers learn how to address healthcare disparities and achieve equity efficiently and effectively.

You can access The Joint Commission’s R3 report (Requirement, Rationale, Reference) for more information about this standard HERE.

You can access resources to support your compliance efforts with these requirements HERE.


Nikki is the Director of Continuous Compliance at Simplifyance, responsible for providing comprehensive, ongoing organizational support in all areas related to healthcare quality, licensure and accreditation, safety and risk management, performance improvement, and regulatory compliance. As a seasoned behavioral healthcare leader with over 20 years of behavioral healthcare experience in both inpatient and outpatient settings, Nikki is known for strong systems thinking and innovative problem-solving in complex service delivery environments. She has been recognized by state leaders for excellence in risk management investigation and follow-up. Nikki is a solutions-focused servant leader who is committed to improving the lives of others and enjoys collaborating with those who are similarly driven. She is a Certified Professional in Healthcare Quality and is based in Fort Myers, Florida. In her free time, she enjoys yoga and staying active outdoors.