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Sentinel Event Alert Addresses Health Care Disparities

The Joint Commission has issued a Sentinel Event Alert, “Addressing health care disparities by improving quality and safety.” The alert helps guide health care organizations to position disparities as a central part of performance and patient safety improvement.

Health care disparities are a critical patient safety and quality issue. Non-Hispanic Black women are three times more likely to die from a pregnancy-related cause than white women.[1] The COVID-19 pandemic has further widened disparity gaps as non-Hispanic Blacks and Hispanics with COVID-19 have experienced nearly three times the rate of hospitalization as whites.[2]

Additionally, racial and ethnic minorities are less likely to receive treatment for depression, substance abuse and other behavioral health conditions.[3] Patients and clients with limited English proficiency face barriers to health care access, experience lower quality care and suffer worse outcomes.[4]

The Sentinel Event Alert provides recommended safety actions health care organizations can take to address disparities and identify opportunities for improvement, including to:

  • Collect and stratify quality and safety performance data specific to the communities the health care organization serves.
  • Develop communication channels to enable listening and learning.
  • Analyze stratified data and community feedback to identify health care disparities and opportunities for improvement.
  • Commit to achieving diversity and inclusion as an important step toward addressing health care disparities.
  • Undertake initiatives to rectify health care disparities by building sustainable business models.

The alert outlines related Joint Commission requirements and provides a list of references and resources for further information about successful practices in addressing health care disparities.

“The Joint Commission is committed to safe, high-quality health care for all,” says Ana Pujols McKee, MD, executive vice president and chief medical officer, chief diversity and inclusion officer, The Joint Commission. “Addressing health care disparities is a top priority for The Joint Commission. Our mission to continuously improve health care commits us to working with health care organizations and other stakeholders to find effective solutions to the inequities that unfortunately have been tolerated in health care much too long.”

[1] Centers for Disease Control and Prevention. Working together to reduce Black maternal mortality. April 9, 2021.
[2] Centers for Disease Control and Prevention. Disparities in COVID-19-associated hospitalizations. Aug. 5, 2021.
[3] Center for Behavioral Health Statistics and Quality. Results from the 2019 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; 2020.
[4]Espinoza J & Derrington S. Should clinicians respond to language barriers that exacerbate health inequity? AMA Journal of Ethics, Feb. 1, 2021.

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