At this level, healthcare facilities are typically early in their inclusion journey and have demonstrated that they have key foundational policies in place for LGBTQ+ inclusion. These policies focus on Patient Non-Discrimination, Equal Visitation and Employee Non-Discrimination--where each must be codified and communicated publicly. Healthcare facilities must also provide some training in LGBTQ+ culturally competent care*. To achieve this tier of recognition, a healthcare facility must receive full credit for all the questions in Criteria 1 - Non-Discrimination and Staff Training.

*Training options (that include CME/CEU credits) are available to facilities that complete the survey.

At this level, in addition to meeting the Foundational Tier of Recognition, Top Performer healthcare facilities have demonstrated that they have adopted a minimum number of LGBTQ+ inclusive policies and practices in Criteria 2: Patient Services and Support, Criteria 3: Employee Benefits and Policies and Criteria 4: Patient and Community Engagement. To achieve this tier of recognition, a healthcare facility must receive full credit in Criteria 1, at least partial credit in Criteria 2 (both scoring sections), 3 and 4, and obtain an overall score between 80-95.

At this level, Leader healthcare facilities demonstrate true leadership in adopting LGBTQ+ policies and practices. To achieve this tier of recognition, a healthcare facility must receive full credit in Criteria 1, 2, 3 and 4 and meet the criteria for the provision of transgender-inclusive health insurance. These facilities receive a top score of 100.

Up to 10 points

1. LGBTQ+ inclusive Patient Non-Discrimination Policy or Patient Bill of Rights
   1. Internal Non-Discrimination and/or Patient Bill of Rights Policy must include the terms “sexual orientation” and “gender identity and expression” (or “gender identity”)
2. Patient non-discrimination is communicated to patients and staff
   1. Policy is shared in two ways with the public, typically online and in-print
   2. Policy is shared with staff in at least one way

View Patient Non-Discrimination Resources for Healthcare Facilities

Up to 10 points

1. Equal Visitation Policy
   1. Policy must allow the patient’s visitor of their choice
2. Equal Visitation Policy is communicated to patients and staff
   1. Policy is shared in two ways with the public, typically online and in-print
   2. Policy is shared with staff in at least one way

View Equal Visitation Resources for Healthcare Facilities

Up to 10 points

1. LGBTQ+ inclusive Employment Non-Discrimination Policy
   1. Internal Employment Non-Discrimination Policy must include the terms “sexual orientation” and “gender identity or expression” (or “gender identity”)
2. Employment Non-Discrimination Policy is shared with the public
   1. Policy is shared with the public in at least one way

View Employment Non-Discrimination Resources for Healthcare Facilities

Up to 5 points

1. REVISED - Baseline Training Requirement in LGBTQ+ Patient-Centered Care
   1. Baseline - Executive Briefing Requirement: For new facilities or those that have not previously met the training requirement, key senior executives must complete the LGBTQ Patient-Centered Care: An Executive Briefing training provided by the HEI
   2. Baseline - 10% Requirement: Returning facilities that have previously met the Executive Briefing requirement must complete a minimum number of staff training hours in LGBTQ+ related topics. The minimum number of hours equals 10% of the number of FTEs at your healthcare facility.

View Staff Training Resources for Healthcare Facilities

Up to 5 points

1. NEW - Training+ Requirement - Additional Training in LGBTQ+ Patient-Centered Care

a. Baseline - Executive Briefing Requirement: The minimum number of hours to meet the “Training +” requirement equals 10% of the number of FTEs at your healthcare facility.

b. Baseline - 10% Requirement: The minimum number of hours to meet the “Training +” requirement is an additional 10% on top of the baseline requirement for a total of 20% of the number of FTEs at your healthcare facility.

Scoring Section One: There are 18 scored questions in these three subsections. In order to receive the full 20 points for these subsections, a facility must have at least 9 or more of these best practices in place from any of these subsections. Facilities with 5 to 8 of these best practices in place will receive a partial score of 10 for these subsections.

Scored best practices include:

• Have a written strategy or plan for reducing health disparities specifically among LGBTQ+ patients and/or explicitly incorporates LGBTQ+ patients into a plan for reducing all patient disparities.

• Have an internal planning or advisory committee focused on LGBTQ+ patient care issues

• Have a publicly available mechanism for interested patients and/or publicly promotes a confidential mechanism to make LGBTQ+ specific referrals to providers within their facility/system

• Provides and promotes HIV specific services

• Provides and promotes LGBTQ+ specific clinical services

• Have an externally promoted LGBTQ+ specific clinic

• Have an externally promoted LGBTQ+ focused office, advocate or LGBTQ+ specific patient navigator or community health worker

• Provides educational LGBTQ+ related health information and/or links to LGBTQ+ health education or service resources from outside organizations

• Create and distribute LGBTQ+ health education brochures or other print materials about specific health topics affecting LGBTQ+ people (distinct from an LGBTQ+ services brochure for marketing purposes)

• New hire training clearly states that the patient non-discrimination policy includes sexual orientation and gender identity and reviews the equal visitation policy and provides definitions or scenarios illustrating how these policies are to be implemented

View LGBTQ Patient Services Resources for Healthcare Facilities

The Gender Affirming Services and Support section utilizes best practices from The Joint Commission and other sources to enhance care for gender diverse patients, who often encounter discomfort and bias when receiving care.

Scored best practices include:

• • Have a written policy (or policies) that specifically outline at least three different processes aimed at eliminating bias and insensitivity, and ensuring appropriate, welcoming interactions with gender diverse patients
  • Offer gender affirming clinical services
  • Have an externally promoted multidisciplinary gender affirming care clinic for either adults and/or youth (distinct from a general LGBTQ+ clinic)
  • Have a program or position to provide patient navigation/advocacy services specifically to gender diverse patients (different from a general LGBTQ+ navigation program)
  • Offer all gender restrooms in public areas for patients and visitors and/or has clearly posted signage indicating a policy that allows individuals to use the restroom that aligns with their gender identity

View Gender Affirming Services Resources for Healthcare Facilities

The Medical Decision Making section emphasizes that patients have the right to appoint anyone they choose, including a same-sex partner, to make medical decisions for them if they become incapacitated. Unfortunately, healthcare organizations have occasionally failed to respect the medical decision-making rights of LGBTQ+ patients. According to 2011 regulations from the Centers for Medicare & Medicaid Services (CMS), it should be more straightforward 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
• Facility has a policy or official practices related to the treatment of intersex children that delays medically unnecessary procedures until the patient is old enough to make an informed decision
  

View Medical Decision Making Resources for Healthcare Facilities

Patient Self-Identification is crucial for healthcare facilities to allow patients the option to identify as LGBTQ+ in their health records if they choose. Incorporating LGBTQ+ self-identification options into an electronic health record system is a significant step a facility can take to help address and reduce LGBTQ+ health disparities.

Scoring Section Two: There are 10 scored questions in this subsection. In order to receive the full 10 points in this subsection, a facility must have at least 6 or more of these best practices in place. Facilities with 3 to 5 of these best practices in place will receive a partial score of 5 for this subsection.

Scored best practices include:

• Electronic health record (EHR) system offers explicit options to capture patient’s current gender identity

• A two-question process is used to collect gender identity information (i.e. first asking current gender identity and subsequently asking sex assigned at birth)

• EHR system offers an explicit way to capture a patient’s anatomical inventory

• EHR system offers explicit options for capturing a patient’s sexual orientation

• EHR system captures the patient’s name in use if it differs from their legal name AND prominently displays this name in the banner, flag, or a pop-up easily accessible for front line staff and providers

• EHR system captures the patient’s pronouns in use AND prominently displays these pronouns in the

• EHR offers multiple options for recording parentage and should include same-sex parents and other diverse families.

• EHR system offers explicit options for recording relationship status with an un-married partner

• Provides staff training specifically about collecting and recording gender identity data in the facility’s EHR system

• Provides staff training specifically outlining LGBTQ+ status as confidential patient information in accordance with HIPAA protections

View Patient Self-Identification Resources for Healthcare Facilities

There are 17 scored questions in this section, In order to receive full 15 points in this subsection, a facility must have at least 8 or more of these best practices in place. Facilities with 4 to 7 of these best practices in place will receive a partial score of 10 points.

Scored best practices include:

Equal Benefits

• Provides healthcare benefits to domestic partners of employees

• REVISED -- Offers LGBTQ+ inclusive financial assistance benefits for family formation such as adoption, foster care, and/or surrogacy assistance programs.

• REVISED -- Covers benefits for clinically based LGBTQ+ inclusive family formation benefits such as fertility treatments, assisted reproductive technologies, and egg and sperm freezing.

• Provides FMLA-equivalent benefits that allow employees to take family and medical leave to care for domestic partners and the children of a domestic partner, regardless of biological or adoptive status

• Have a LGBTQ+ inclusive paid, long-term family leave policy that allows paid time off to care for domestic partners as well as the children of a domestic partner, regardless of biological or adoptive status and parental leave policies that do not exclude non-birth parents and do not discriminate in access to benefits based on sex, sexual orientation, gender identity and marital status

• Provides bereavement leave benefit that includes the event of the death of a domestic partner or the partner’s immediate family

• Provide at least one health plan to all employees that affirmatively and explicitly covers medically necessary health services for transgender people, including gender transition-related treatment.

• NEW – Provide health insurance coverage for gender-affirming care goes beyond the HEI baseline requirements for coverage (see Healthcare Benefits Impacting Gender Diverse Employees question below) and provides coverage for certain other essential services and treatments

• Provides employees with an LGBTQ+ benefits guide upon hire and annually during open enrollment OR organization provides access to a benefits concierge service with an LGBTQ+ specialty

Additional Support for LGBTQ+ Employees

• Have written gender transition guidelines documenting supportive policies and practices on issues pertinent to a workplace gender transition with a minimum of supportive restroom, dress code and documentation guidance

• Have an officially recognized an LGBTQ+ employee resource group

• Have a diversity & inclusion office, diversity council or working group focused on employee diversity specifically includes LGBTQ+ diversity as part of its mission

• Conducts an anonymous employee engagement or climate surveys allow employees the choice to identify as LGBTQ+

• The anonymous employee engagement or climate surveys include specific question(s) related to LGBTQ+ concerns.

• Confidential human resources information system (HRIS) captures sexual orientation and/or gender identity (if voluntarily disclosed) along with other demographic information such as race and gender

• Commemorates an LGBTQ+ Awareness Day for employees at the facility

• Have explicitly LGBTQ+ inclusive hiring efforts

• Have openly LGBTQ+ people serving in high-level visible leadership positions

View Employee Benefits & Policies Resources for Healthcare Facilities

The question in this subsection is scored independently (5 points) and must be met in order to attain Leader status.

Equal health coverage for gender diverse individuals for medically necessary care. Baseline coverage MUST include the following items:

• Mental health benefits

• Pharmaceutical coverage (hormone replacement therapies, puberty blockers for youth)

• Coverage for medical visits or laboratory services

• Coverage for reconstructive surgical procedures related to gender affirming surgery (including reconstructive chest, breast, and genital procedures and related medically necessary procedures such as hair removal prior to genital procedures and revisions)

• Short-term medical leave

• Covered gender affirming treatments and procedures must be clearly listed in the contract documentation and the scope of each benefit must be described clearly in the employee benefits materials so that employees and their eligible dependents can easily understand what is covered

• The plan must eliminate other barriers to coverage.

Scored best practices include:

LGBTQ+ Community Engagement and Marketing

• REVISED - Supports/sponsors one or more LGBTQ+ related external community event(s) or initiative(s) in the facility’s service area

• NEW – Hosts/organizes one or more LGBTQ+ related event(s) or initiative(s) for the broader LGBTQ+ community and/or their LGBTQ+ patients

• Engages in LGBTQ+ inclusive marketing or advertising to the LGBTQ+ community

• Includes LGBTQ+ content and/or images in its organic social media posts at least four separate times per year, with at least one post on a transgender-specific topic

• Have a LGBTQ+ specific logo that is used externally online, in marketing materials, or in other community engagement efforts

• Have a supplier diversity program includes a demonstrated effort to include certified LGBTQ+ suppliers (must be evident in public-facing materials)

• Publicly supported LGBTQ+ equality under the law through acting on local, state, or federal legislation or regulations

Understanding the Needs of LGBTQ+ Patients and Community

• Patient satisfaction surveys allow patients the option to identify as LGBTQ+

• Patient satisfaction survey includes specific LGBTQ+ related questions (general discrimination and inclusion questions do not meet the criteria.

• Work with external LGBTQ+ organizations or community members to assess and address LGBTQ+ health needs or concerns

• Include external LGBTQ+ community member(s) on a governing or community advisory board

• Support LGBTQ+ health-related academic and/or clinical research

• Analyze patient satisfaction and/or EHR data with an intersectional LGBTQ+ lens to identify LGBTQ+ health and programmatic needs

View Patient & Community Engagement Resources for Healthcare Facilities

This section focuses on known activities that undermine LGBTQ+ equality or patient care.

Healthcare organizations can have points deducted from their score if they have policies in place that may lead to discriminatory treatment or a large-scale official or public anti-LGBTQ+ blemish on their recent records.

Both a major deduction of 25 points and a minor deduction of 5 points exist.

Major Deduction

The deduction of 25 points is for major offenses to the LGBTQ+ that come to the attention of the HRC Foundation. These offenses could include revoking LGBTQ+ inclusive policies and practices or having policies in place and/or engaging in proven practices that are contrary to the organization's written LGBTQ+ patient or employment policies, among other infractions. This deduction is rarely applied and will only be applied after prior notification and discussion with the facility.

Minor Deduction

The deduction of 5 points is specific to healthcare facilities that either follow a religious directive or have a policy in place that prevents them from providing specific medically necessary treatments. For example, under such policies procedures such as hysterectomy or mastectomy, would be denied to some patients based on a diagnosis of gender dysphoria, however the same treatment would be provided to other patients based on other diagnoses. This may result in discriminatory treatment that is in conflict with their non-discrimination policy—for this we would implement the minor deduction (which offsets the points received for the Patient Non-Discrimination Policy).

Facilities with this type of directive or policy in place will only receive the minor deduction if they take certain actions to mitigate the potential for discriminatory situations to occur. If the facility does not mitigate the potential for discriminatory situations, the facility may receive the major deduction.

Please see our website for more information about this criterion.