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HEI Scoring Criteria

The Healthcare Equality Index 2018 continues use of the new scoring criteria that was announced in 2015 and implemented during 2017's survey cycle. Since its inception in 2007, the HEI has successfully encouraged hospitals and other healthcare facilities across the nation to adopt LGBTQ-inclusive patient, visitation, and employment policies. Over time and due to decade of advancement in LGBTQ inclusion in daily life, healthcare facilities have worked harder than ever to increase their work to provide equitable care for the LGBTQ community — and now the HEI survey reflects and promotes these efforts through its new scoring criteria.

Download a PDF summary of the HEI 2018 Scoring Criteria

Under the scoring system, a facility needs to receive a score of 100 points to be designated as a “Leader in LGBTQ Healthcare Equality.” Facilities receive points for meeting specific requirements and by having a certain number of best practices and policies in place.

The HEI 2018 implements four core objectives:

  1. Ensure foundational protection for patients, visitors and staff in patient and staff policies and provide cultural competency training on LGBTQ inclusion
  2. Demonstrate progress toward inclusion on LGBTQ patient care and support
  3. Cultivate an inclusive workforce by providing LGBTQ-inclusive employee support and benefits
  4. Demonstrate public commitment to the LGBTQ community

The survey is divided into five scoring criteria:

  1. Non-Discrimination & Staff Training
  2. Patient Services & Support
  3. Employee Benefits & Policies
  4. Patient & Community Engagement
  5. Responsible Citizenship

With the exception of the Non-Discrimination & Staff Training criteria, which contains the previous Leader criteria, the scoring criteria for the HEI was intentionally designed to be flexible and to allow facilities to select from a menu of best practices in order to receive points for that section. Facilities may receive full, partial or no credit for each criteria depending upon how many of the policies and practices they have in place. In many cases, a facility will be required to upload documentation to validate implementation of the best practice. Credit will not be given for policies and best practices that cannot be validated.

1. Non-Discrimination & Staff Training

Up to 40 points

The Non-Discrimination and Staff Training criteria represents policies and practices that are considered foundational to LGBTQ patient-centered care. This criteria encompasses what was previously considered the “Core Four Leader Criteria.” All questions in this section are scored and must be met in order to attain Leader status.

Patient Non-Discrimination
Up to 10 points

  • Patient Non-Discrimination Policy is LGBTQ-Inclusive (5 points)
  • Policy must include the terms “sexual orientation” and “gender identity and expression” or “gender identity”
  • Patient Non-Discrimination Policy is communicated to patients and staff (5 points)
  • Policy is shared in two ways with the public, typically online and in-print
  • Policy is shared in one way with staff

View Patient Non-Discrimination Resources for Healthcare Facilities

Equal Visitation
Up to 10 points

  • Visitation Policy is LGBTQ-Inclusive (5 points)
    • Policy must allow the patient’s visitor of their choice
  • Equal Visitation Policy is communicated to patients and staff (5 points)
    • Policy is shared in two ways with the public, typically online and in-print
    • Policy is shared in one way with staff

View Equal Visitation Resources for Healthcare Facilities

Employment Non-Discrimination
Up to 10 points

  • Employment Non-Discrimination Policy is LGBTQ-Inclusive (5 points)
  • Policy must include the terms “sexual orientation” and “gender identity or expression” or “gender identity”
  • Employment Non-Discrimination Policy is communicated to the public (5 points)
  • Policy is shared in one way with the public

View Employment Non-Discrimination Resources for Healthcare Facilities

Staff Training
Up to 10 points

  • Training in LGBTQ Patient-Centered Care is completed (5 points)
    • For first year facilities, senior executives must complete the “LGBTQ Patient-Centered Care: An Executive Briefing” course training provided by the The Center for Affiliated Learning (The CAL)
    • OR
    • Returning facilities must complete at least 25 hours of staff training in LGBTQ-related topics, either clinical or broader training.
  • Training in LGBTQ Patient-Centered Care is promoted to staff (5 points)
    • Facilities must communicate the training options available to staff

View Staff Training Resources for Healthcare Facilities

2. Patient Services & Support

Up to 30 points

The LGBTQ Patient Services section is designed to familiarize your organization with the best practices from The Joint Commission and other sources to enhance care to LGBTQ patients.

There are 22 best practices that are scored questions in this criteria. In order to receive full credit (30 points) for this criteria, a facility must have implemented 11 or more of the best practices. A facility may receive partial credit (15 points) for this criteria if it has implemented 6 to 10 of the best practices.

The 22 scored questions in this criteria come from the following sections:

LGBTQ Patient Services
Scored best practices include:

  • Have a written strategy or plan for reducing health disparities among LGBTQ patients and/or incorporate LGBTQ patients into your plan for reducing all patient disparities
  • Have an internal planning or advisory committee focused on LGBTQ patient care issues (new)
  • Publicly make LGBTQ-knowledgeable and friendly providers or facilities known as such to interested patients or provide a confidential mechanism to make LGBTQ-specific referrals (revised)
  • Provide some LGBTQ-specific clinical services
  • Review clinical services to identify LGBTQ-related gaps
  • Have an external LGBTQ-focused office or ombudsman (revised)
  • Provide LGBTQ-related health information on the facility’s website
  • Create a brochure or other print material to support LGBTQ patients
  • Make external LGBTQ health resources available to patients

View LGBTQ Patient Services Resources for Healthcare Facilities

Transgender Patient Services and Support
The Transgender Patient Services and Support section utilizes best practices from The Joint Commission and other sources to enhance care for transgender patients, who often encounter discomfort and bias when receiving care.

Scored best practices include:

  • Have a written policy (or policies) that specifically outline procedures and practices aimed at eliminating bias and insensitivity, and ensuring appropriate, welcoming interactions with transgender patients
  • Offer some transgender specific clinical services
  • Have a specific program or position to provide patient navigation/advocacy services to transgender patients (revised)
  • Offer gender neutral restrooms in public areas for patients and visitors

View Transgender Patient Services Resources for Healthcare Facilities

Patient Self-Identification
Patient Self-Identification is important for healthcare facilities to provide patients the opportunity to be identified as LGBTQ in health records, if they so wish. Adding LGBTQ self-identification options to your electronic health record system is a significant step your facility can take to help end LGBTQ health disparities with LGBTQ self-identification options.

Scored best practices include:

Collecting information about sexual orientation and gender identity through the following:

  • Electronic health records that offer explicit options to capture patient’s current gender identity if it differs from the sex they were assigned at birth
  • A two-question process used to collect gender identity information identity (i.e. first asking current gender identity and then asking sex assigned at birth)
  • Training is provided to staff on how to collect and record gender identity data
  • Electronic health records that offer explicit options for capturing patient’s sexual orientation if they choose to volunteer that information
  • Employees that are provided training explicitly reminding them that LGBTQ status is confidential patient information

Providing LGBTQ family inclusive health records with:

  • Electronic health records that offer explicit options for recording parents that are inclusive of same-sex parents and other diverse families
  • Electronic health records that offer explicit options for recording relationship status with an unmarried partner

View Patient Self-Identification Resources for Healthcare Facilities

Medical Decision Making
The Medical Decision Making section highlights the right of patients to designate the person of their choice, including a same-sex partner, to make medical decisions on their behalf if they ever became incapacitated. Unfortunately, healthcare organizations have sometimes failed to honor LGBTQ patients’ medical decision making rights. As noted by CMS in 2011 regulations, it should be easier for family members, including same-sex partners, to make informed care decisions for incapacitated loved ones.

Scored best practices include:

  • Organization explicitly informs patients of their right to designate a person of their choice, including a domestic partner, as medical decision-maker
  • Organization offers employee training related to medical decision making that includes LGBTQ specific information

View Medical Decision Making Resources for Healthcare Facilities

3. Employee Benefits & Policies

Up to 20 points

This criteria focuses on the employee as much as the patient in providing inclusive care. These questions don’t only cover health insurance benefits, but also address employee resources groups, LGBTQ-inclusive hiring efforts, transgender inclusive healthcare benefits, employee transition support, and much more.

There are 15 scored questions in this section. In order to receive the full 20 points, your facility must have at least 7 or more of these best practices in place. Facilities that have 4 to 6 of these best practices in place will receive a partial score of 10 for this criterion.

View Employee Benefits & Policies Resources for Healthcare Facilities

Scored best practices include:

Equal Benefits

  • Health insurance policy’s definition of spouse includes same sex spouses
  • Same documentation is required for enrollment of same and opposite sex spouses
  • Healthcare benefits are provided to domestic partners
  • COBRA-equivalent benefits are provided to domestic partners
  • FMLA-equivalent benefits allow employees to take family and medical leave to care for domestic partners as well as the children of a domestic partner, regardless of biological or adoptive status
  • Bereavement leave allowed in the event of the death of a domestic partner or their immediate family

Benefits and Policies Impacting Transgender Employees

  • Provide at least one health plan to all employees that explicitly covers medically necessary health services for transgender people, including gender transition-related treatment
  • Organization has written gender transition guidelines documenting supportive policies and practices on issues pertinent to a workplace gender transition

Additional Support for LGBTQ Employees

  • Organization has an officially recognized LGBTQ employee resource group
  • Organization has a diversity and inclusion office, diversity council or working group focused on employee diversity that specifically includes LGBTQ diversity as part of its mission (new)
  • Anonymous employee engagement or climate surveys allow employees the option to identify as LGBTQ
  • Anonymous employee engagement or climate surveys include question(s) related to LGBTQ concerns
  • Commemorate an “LGBTQ Holiday” at the facility
  • Have explicitly LGBTQ-inclusive hiring efforts
  • Organization has openly LGBTQ people serving in high level visible leadership positions (new)
4. Patient & Community Engagement

Up to 10 points

The Patient & Community Engagement criteria focuses on community outreach and promotion to let the LGBTQ community know you are a welcoming and affirming facility, working toward LGBTQ inclusion.

In order to receive full credit (10 points) for this section, a facility must have implemented 4 or more of the best practices. A facility may receive partial credit (5 points) for this criteria if it has implemented 2 to 3 of the best practices.

View Patient & Community Engagement Resources for Healthcare Facilities

Scored best practices include:

LGBTQ Community Engagement and Marketing

  • Support one or more LGBTQ related events or initiatives in the facility’s service area
  • Engage in LGBTQ-inclusive marketing or advertising to the LGBTQ community
  • Have an LGBTQ-specific logo (new)
  • Organization has publicly supported LGBTQ equality under the law through local, state, or federal legislation or initiatives (new)

Understand the Needs of LGBTQ Patients and Community

  • Patient surveys allow patients the option to identify as LGBTQ
  • Patient surveys include LGBTQ related questions
  • Organization works with LGBTQ organizations or community members to assess LGBTQ needs or address LGBTQ-related concerns (revised)
  • Include external LGBTQ representation on a governing or community advisory board
  • Support LGBTQ health-related research
5. Responsible Citizenship

-25 points

This section focuses on known activity that would undermine LGBTQ equality or patient care. Healthcare facilities will have 25 points deducted from their score for a large-scale official or public anti-LGBTQ blemish on their recent records.

Scores on this criterion are based on information that has come to HRC Foundation’s attention related to topics including but not limited to: 

  • Revoking LGBTQ-inclusive policies or practices;
  • Facilitating the continued practice of healthcare providers that provide or promote LGBTQ related treatment or services to that have been discredited by mainstream medical and mental health organizations, including, but not limited to, “conversion therapy”;
  • Engaging in proven practices that are contrary to the facility's written LGBTQ patient or employment policies;
  • Advocating for public policies or regulations that would be detrimental to LGBTQ equality and/or health;
  • Directing charitable contributions or other public support to organizations whose primary mission includes advocacy against LGBTQ equality or care.

Prior to applying the point deduction, the HRC Foundation will make every attempt to work with the organization to resolve the concerns. If it is necessary to apply the point deduction, it may be reflected in a current or future score, depending on the situation. If applied to a current score, HEI Leader in LGBTQ Healthcare Equality status will be suspended or revoked as necessary. If at any time after losing points on this criterion, a healthcare facility changes course and satisfies the HRC Foundation’s noted concerns, HRC Foundation will re-evaluate the criterion for that facility.

HRC realizes that no institution is perfect and that situations may arise where an individual or small group act in a way that is not in alignment with the organization’s policies and commitment to LGBTQ equality and patient care. This criterion is not intended to penalize an organization in those situations where an isolated negative action takes place, provided that the organization addresses the situation and takes action to ensure that their commitment to LGBTQ patient care remains uncompromised.

In the cases where HRC would consider applying the responsible citizenship deduction based on the actions of one individual employed by the hospital, health system or affiliated university, we would only do so after looking at the totality of the situation and considering the following factors:

  • The breadth and depth of the action(s) by the employee and the potential damage that could be done to the LGBTQ community.
  • The environment, context and history of the organization as it relates to the actions of the employee.
  • The response of the organization and whether or not they have responded in a way to mitigate the harm caused by the actions.

In the HEI 2017, only one hospital, Johns Hopkins Hospital, received this point deduction.
Learn Why They Received the Deduction