Improving health outcomes for all the hospital’s patients is a quality and safety priority.

(1)

The hospital designates an individual(s) to lead activities to improve health outcomes for all the hospital's patients. Note: Leading the hospital’s activities to improve health outcomes for all may be an individual’s primary role or part of a broader set of responsibilities.

(2)

The hospital assesses the patient’s health-related social needs (HRSNs) and provides information about community resources and support services. Note 1: Hospitals determine which HRSNs to include in the patient assessment. Examples of a patient’s HRSNs may include the following: - Access to transportation - Difficulty paying for prescriptions or medical bills - Education and literacy - Food insecurity - Housing insecurity Note 2: HRSNs may be identified for a representative sample of the hospital’s patients or for all the hospital’s patients.

(3)

The hospital identifies differences in the care provided to its patient population by stratifying quality and safety data using the sociodemographic characteristics of the hospital’s patients. Note 1: Hospitals may focus on areas with known differences across populations identified in the scientific literature (for example, organ transplantation, maternal care, diabetes management) or select measures that affect all patients (for example, experience of care and communication). Note 2: Hospitals determine which sociodemographic characteristics to use for stratification analyses. Examples of sociodemographic characteristics may include the following: - Age - Gender - Preferred language - Race and ethnicity - Veterans - Patients in rural communities - Physical, mental, and cognitive disabilities

(4)

The hospital develops a written action plan that describes how it will improve health outcomes for all by addressing at least one of the differences identified in the care provided to its patient population.

(5)

The hospital acts when it does not achieve or sustain the goal(s) in its action plan to improve health outcomes for all.

(6)

At least annually, the hospital informs key stakeholders, including leaders, licensed practitioners, and staff, about its progress to improve health outcomes for all.