Why Every Employee Needs to Understand Your Facility’s Commitment to Equitable, Person-Centered Care.
In April 2022, the Centers for Medicare & Medicaid Services (CMS) announced that advancing health equity would become a key pillar of its overall strategy for improving healthcare delivery and quality. The move was reinforced in updated State Operations Manual (SOM) guidance released in October 2022, which included language urging nursing homes to embed health equity considerations into their QAPI (Quality Assurance and Performance Improvement) plans.
This directive wasn’t arbitrary. CMS recognized longstanding disparities in healthcare outcomes—particularly among racial and ethnic minorities, non-English speakers, LGBTQ+ populations, residents with disabilities, and those from low-income backgrounds. Facilities were encouraged to acknowledge and address these gaps by including equity-focused objectives in their continuous improvement efforts.
What Is a Health Equity Statement in the QAPI Plan?
The Health Equity Statement in your QAPI plan is a formal commitment to fair, inclusive, and person-centered care. It signals to your staff, residents, families, and surveyors that your facility is not only aware of health disparities but also actively working to eliminate them.
This is more than regulatory compliance it reflects your facility’s values and your commitment to quality for every resident, every time.
What Should the Health Equity Statement Include?
Sample Health Equity Statement for QAPI Plan:
"[Facility Name] is committed to advancing health equity by ensuring that every resident receives person-centered, culturally competent care that meets their individual needs and promotes the highest quality of life. We proactively identify and address health disparities that may exist within our resident population by collecting and analyzing demographic data, resident feedback, and quality metrics. Through staff training, interdisciplinary collaboration, and targeted quality improvement initiatives, we aim to eliminate barriers to care and ensure equitable health outcomes for all residents, regardless of race, ethnicity, language, disability, gender identity, sexual orientation, or socioeconomic status."
What Does This Mean for Facility Leadership?
Facility leadership should understand that this is not just a “compliance item”—it’s a call to action. The work you do in your QAPI committee should reflect your commitment to equity in the following ways:
Proactive Data Collection
- Track demographics, outcomes, and complaints by subgroups.
- Look for gaps in clinical outcomes, resident satisfaction, or care access.
Root Cause Analysis of Disparities
- Ask: Why are certain groups at higher risk for rehospitalization or pressure injuries?
- Identify barriers like communication issues, bias, or lack of cultural awareness.
Targeted Interventions
- Introduce interpretation services, culturally relevant menus, or staff coaching.
- Prioritize equity-driven projects in your QAPI work plan.
Staff Education
- Train all staff (not just clinical) on what health equity means and how their actions matter.
- Include it in competencies, in-services, and QAPI team agendas.
Resident and Family Engagement
- Use satisfaction surveys, grievance logs, and care plan meetings to include underrepresented voices.
- Encourage resident councils to discuss inclusivity and respect in care.
As CMS continues to embed health equity into its expectations for long-term care providers, your facility’s ability to respond with intention and structure is critical. Incorporating a well-crafted Health Equity Statement into your QAPI plan demonstrates leadership and integrity—and it lays the foundation for better outcomes and stronger compliance.
For help developing your QAPI plan, identifying disparities, or launching equity-based improvement initiatives, reach out to the Polaris Group. Our consultants are ready to assist with firsthand support and strategic planning tailored to your facility’s needs.
Sources:
CMS Health Equity Framework 2022 – https://www.cms.gov
State Operations Manual Appendix PP (Revised October 2022)
QAPI at a Glance – Centers for Medicare & Medicaid Services
CMS Memo QSO-22-09-NH – “Nursing Home Guidance to Improve Resident Safety” (April 2022)
