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Health Systems Start Gaining Accreditation for Health Equity Work

Analysis  |  By Christopher Cheney  
   September 18, 2023

National Committee for Quality Assurance health equity accreditation features six standards such as organizational readiness and availability of language services.

In a sign of the growing number of healthcare providers addressing health equity, York, Pennsylvania-based WellSpan Health has become one of three health systems to earn National Committee for Quality Assurance (NCQA) health equity accreditation.

Health equity has become a top priority for healthcare providers nationwide. Last year, health equity was added as the Quintuple Aim for healthcare providers. In 2008, the Triple Aim for healthcare improvement was introduced, featuring improvement of population health, enhancement of the care experience, and reduction of costs. In 2014, the Quadruple Aim for healthcare improvement was created with the addition of workforce well-being as a fourth element to address healthcare worker burnout.

In July 2021, the Health Information and Management Systems Society conducted a survey of hospital executives for the consultancy BDO regarding the executives' plans to understand, address, and measure health equity challenges. The survey found widespread adoption of health equity strategies or plans to implement health equity strategies:

  • 37% of the hospitals had a health equity strategy in place
  • 37% of the hospitals were planning to implement a health equity strategy in the next 12 months
  • 13% of the hospitals were planning to implement a health equity strategy in the next 12 to 24 months
  • 9% of the hospitals were planning to implement a health equity strategy after 24 months
  • Only 5% of the hospitals did not have plans to implement a health equity strategy

NCQA health equity accreditation is based on six core standards:

  • Organizational readiness such as building a diverse staff
  • The ability to gather race, ethnicity, language, gender identity, and sexual orientation data
  • Availability of language services
  • Practitioner network cultural responsiveness to diverse populations
  • Culturally and linguistically appropriate services that meet the needs of diverse populations
  • The ability to use data to assess the existence of healthcare disparities and the use of quality improvement initiatives to decrease healthcare disparities

WellSpan's health equity journey

WellSpan took an innovative approach by building a comprehensive health equity program, says Michael Seim, MD, senior vice president and chief quality officer of the health system. "With the work that we did to achieve NCQA accreditation, we had to make sure that we had the underlying infrastructure to be successful. We are working on looking at every aspect of our work at WellSpan through the lens of health equity. For example, we are working on a children's health initiative to make sure we set up children under the age of 6 to be healthy."

A primary focus of health equity work at WellSpan is decreasing life expectancy disparities, he says. "Throughout the country, there are disparities in life expectancy based on whether you live in an urban or rural area, whether you have access to education, whether you have access to housing, and whether you have access to healthy food. So, we are working on this issue as part of our community health needs assessment, our community health improvement plan, and our strategic plans. We are trying to look at all angles, including through a lens of equity."

WellSpan is taking an innovative approach to reducing life expectancy disparities, Seim says. "That focus is innovative in the fact that we have to tie together every aspect of not only our clinical practices within WellSpan but also within our community health work and our partnership programs."

WellSpan's health equity work has been based on a step-by-step process, he says. "We have to do things like support education and businesses in our communities. We must be committed to our diversity, equity, and inclusion program to build a reflective workforce within our service area. We must find key partners who share our vision because we cannot address many of the social drivers of health without key partners. We must make sure our philanthropic work, charity work, and community benefits are being honed to our mission of health for all. Then we must engage our medical groups to say, 'OK. What are the leading causes of death within our communities and are we putting the resources in to address these causes of death?' For example, we are making efforts in smoking cessation, hypertension control, and screening for colorectal and breast cancer."

WellSpan started doing health equity work before the market demanded it, Seim says. "Going back to 2017, we set up the infrastructure to screen patients for social drivers of health. We set up the process of prioritizing health equity by building a health equity steering committee. Four years ago, we set up strategic goals by our board of directors as part of our annual plan to achieve measurable outcome results in health equity. There are other health systems that are just working on process measures, but we are committed to outcome measures where we can show that we have improved the health of our communities."

Health equity work outcomes

WellSpan is monitoring several metrics to gauge the impact of the health system's equity work, Seim says. These metrics include Healthcare Effectiveness Data and Information Set measures, kidney health, colorectal and breast cancer screening, hypertension management, immunizations, and food security and housing security.

WellSpan has made significant progress in health equity efforts related to severe maternal morbidity and mortality, COVID-19 disparities, and food and housing insecurity, according to health system data.

  • An outcome-based goal was established to decrease severe morbidity and mortality associated with pre-eclampsia (hypertension). In calendar year 2018, the total number of severe maternal morbidity and mortality cases was 39 with an overall rate of 7.6%. Fiscal year 2020 hypertension outcome data demonstrated a 54% decline in severe morbidity and mortality among all races. Additionally, a 61% reduction in the rate of severe morbidity and mortality related to hypertension among Black individuals as compared to the baseline was also noted.
  • During the initial stages of the coronavirus pandemic, Black and Latino families were disproportionally impacted by COVID-19. Through data analysis and comparing infection rates among diverse populations, WellSpan was able to make strategic decisions, build key community partnerships, and allocate grants early in the pandemic, which resulted in a significant rate reduction of COVID-19 infections among ethnic and racial groups. The fiscal year 2022 annual plan also identified a disparity in vaccination rates between patients who identified as being non-white or identified a primary language other than English when compared to white and English-speaking patients. WellSpan expanded community, patient, and family partnerships to understand the needs of the community and explore barriers to vaccinations and routine screening. This significantly decreased the vaccination rate disparity between populations.
  • Since calendar year 2020, screening for food and housing insecurity has increased. During the first year of the program, WellSpan screened 55,792 unique patients and 5% of those screened were identified as having a need for housing or food. From October 1, 2021, to April 22, 2022, a six-month screening period, 19,051 patients were identified with a food insecurity, 16,044 patients were identified with housing instability, and 11,133 lacked transportation, and they were referred to a community partner program, case manager, or WellSpan program.

Related: Health Equity: 'First and Foremost it is a Moral Imperative'

Christopher Cheney is the CMO editor at HealthLeaders.


According to survey data, only 5% of hospitals did not have plans to implement a health equity strategy.

WellSpan Health earned National Committee for Quality Assurance health equity accreditation by implementing an innovative comprehensive health equity program.

WellSpan is monitoring several metrics to gauge the impact of the health system's equity work, including HEDIS measures, kidney health, colorectal and breast cancer screening, hypertension management, immunizations, and food security and housing security.

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