Accountable Healthcare - National Patient Safety Goal to Improve Health Care Equity-Goal 16
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July 31, 2023

National Patient Safety Goal to Improve Health Care Equity-Goal 16

There is an updated NPSG Goal: 16- Improve Health Care Equity. Please review the 6 elements of performance (EPs) for improving health care equity as a quality and safety priority.

Organizations are required to do the following:

Identify individual(s) to lead activities to improve health care equity

  • Assess the patient’s health-related social needs (HRSN)

HSRNs may include the following:

  • Access to transportation
  • Difficulty paying for prescriptions or medical bills
  • Education and literacy
  • Food insecurity
  • Housing insecurity

Analyze quality and safety data to identify disparities

The organization identifies health care disparities in its patient population by stratifying quality and safety data using the sociodemographic characteristics of the organization’s patients. Examples of sociodemographic characteristics may include the following: • Age • Gender • Preferred language • Race and ethnicity.

Develop an action plan to improve health care equity

The organization should develop an action plan that defines the health care disparity and the specific population(s) of focus, the organization’s improvement goal, the strategies and resources needed to achieve the goal, and the process that will be used to monitor and report progress.

  • Take action when the organization does not meet the goals in its action plan
  • Inform key stakeholders about progress to improve health care equity

NPSG16.01.01 will apply to the following Joint Commission–accredited organizations:

  • All critical access hospitals and hospitals
  • Ambulatory health care organizations providing primary care within the “Medical Centers” service in the ambulatory health care program (the requirements are not applicable to organizations providing episodic care, dental services, or surgical services)
  • Behavioral health care and human services organizations providing “Addictions Services,” “Eating Disorders Treatment,” “Intellectual Disabilities/Developmental Delays,” “Mental Health Services,” and “Primary Physical Health Care” service

r3_npsg-16.pdf (

Article by:
Kelly Gunn, MBA, RN
Senior Director, Clinical Services
Accountable Healthcare Staffing, Inc.