Success Story: WellSpan’s Health Equity Accreditation Experience

January 27, 2025 · Becky Kolinski

Are you considering pursuing NCQA’s Health Equity Accreditation? If you’re exploring whether this program is right for you, you might want to hear from organizations, like WellSpan, that have successfully completed the journey.

WellSpan is an integrated health system with more than 23,000 team members across 13 counties in central Pennsylvania and northern Maryland, delivering high-quality, safe, reliable and equitable care in inpatient and ambulatory settings. Pursuing NCQA Health Equity Accreditation was a natural progression for WellSpan—57 of its medical practices have earned Patient-Centered Medical Home Recognition, and its Population Health services have earned Case Management and Utilization Management Accreditation.

“We have a long history of serving the needs of our community and improving access to care for all people,” says Dr. Mike Seim, Senior Vice President and Chief Quality Officer at WellSpan. “Pursuing Health Equity Accreditation gave us an opportunity to further refine our processes and identify areas where we had opportunities or could make improvements toward equitable care.”

Getting Leadership Buy-In

Sustained, impactful health equity work requires strong leadership and a willingness to prioritize health equity as a way of doing business, with specific objectives and dedicated resources. Health Equity Accreditation was a vehicle for Dr. Seim and WellSpan’s CEO, Dr. Roxanna Gapstur, to drive organizational changes and communicate health equity-focused goals to every part of the organization.

Performing a Gap Analysis

Although WellSpan had a long history with health equity and quality improvement, a gap analysis identified key areas for improvement.

• Data Collection. WellSpan collected data on race, ethnicity and language, but not on sexual orientation and gender identity.
• Process Improvement. WellSpan had experience providing culturally and linguistically appropriate services, but wanted to make its health equity practices more structured and sustainable.
• Patient Experience. WellSpan collected data on patient experience, but hadn’t reviewed the data through a health equity lens.

“The gap analysis was enlightening and really helped shape our equity initiatives moving forward,” says Ann Kunkel, VP Community Health, Home Care and Hospice. “The Accreditation process created a framework for us to align our processes with established standards and best practices.”

Navigating the Survey Process

Organizing the information and managing the survey process is a significant undertaking that requires a team approach. Although WellSpan does not have a dedicated “health equity team,” it was able to leverage multidisciplinary collaboration across departments, such as Quality, Community Health and Engagement and Diversity, Equity and Inclusion. Each leader identified individuals from their team to join the project.

“We were able to harness the passion and dedication of our employees to prepare for the survey,” says Holly Wolfe, Senior Director of Quality. “The team’s strong analytic capabilities and prior experience working with CMS and state regulators were essential for our success.”

WellSpan established a Health Equity Steering Committee that reports to the Board of Directors. Dr. Seim provided executive oversight, and the team leaned heavily on the expertise of key departments—Community Health and Engagement, Language Services and Quality Management. The presence of an effective project manager helped organize meetings and ensure the right participants were engaged.

Improving Organizational Performance

Accreditation provided a framework for WellSpan to refine existing processes and accelerate change in the organization.

• Create Alignment. The Accreditation standards helped demonstrate how each part of WellSpan’s operations contributes to its goals of improving patients’ health, access to care and overall experience.
• Encourage a Proactive Approach. The Health Equity Accreditation empowered WellSpan to be proactive and intentional about identifying and selecting its focus areas—a capability it’s using to tune in to the unique needs of diverse populations.
• Improve Employee Engagement. The Accreditation allowed WellSpan to increase employee engagement by cultivating a culture of equity where staff view themselves as allies to their patients and to each other.

WellSpan’s Health Equity Accreditation has also been a springboard for public speaking engagements and recognition of its commitment to quality and equity, including winning the American Hospital Association’s Quest for Quality Prize in 2024.

Reducing Health Disparities

Pursuing Health Equity Accreditation propelled WellSpan’s efforts to reduce disparities in care and embed health equity goals in all aspects of care delivery—for example, its project focused on closing the disparity gap in breast cancer screening and colorectal cancer screening. By creating new variables for race, population of color and language, WellSpan was able to identify disparities, implement culturally and linguistically appropriate outreach and address patients’ social drivers of health.

These efforts led to positive improvements in health outcomes and projected life expectancy for people of color.

• Breast cancer screening rates for people of color improved by 6.31% from MY 2022 to MY 2023, preventing an estimated 15 breast cancer deaths and adding 215 years of life.
• Colon cancer screening rates improved by 8.73% for people of color from MY 2022 to MY 2023, preventing an estimated 360 colorectal cancer deaths and adding 4,053 years of life.

“One of the benefits of NCQA’s Health Equity Accreditation is our ability to measure progress objectively,” says Dr. Seim. “We have the data to identify disparities in health outcomes and track our progress in closing the gaps—and that leads to more equitable care for all patients.”

Learn More

• Visit our website to learn more about NCQA’s Health Equity Accreditation.
• Download our Health Equity Accreditation Program Toolkit.
• Take an online course: Multi-Cultural Resources and Tools to Engage Members and Communities.