to main content Hackensack University Medical Center - HCE | The Joint Commission

Recently, Hackensack University Medical Center (HUMC) in New Jersey became the first in the nation to achieve The Joint Commission’s Health Care Equity (HCE) Certification. This certification provides the structure to bridge the gap to equitable care by looking at equity issues in all aspects of care, treatment, and health care delivery.

Participating interviewees included:

  • Mark D. Sparta, FACHE, President and Chief Hospital Executive at HUMC and North Region President at Hackensack Meridian Health
  • Avonia Richardson-Miller, Senior Vice President and Chief Diversity Officer at Hackensack Meridian Health
  • Dr. Nicole Harris-Hollingsworth, Vice President for Social Determinants of Health at HUMC 
  • Dr. Chinwe Ogedegbe, Emergency Medicine Attending and Health Equity Lead at HUMC 
  • Darryl Hughes, Diversity, Equity and Inclusion Partner at HUMC
  • Barry Pace, Nurse Manager at HUMC
  • Inia Estima, Director, Regulatory Affairs at Hackensack Meridian Health
  • Peter Lomuscio, Manager of Regulatory Affairs at Hackensack Meridian Health

Q: What kind of provider organization is HUMC?

Mark Sparta: HUMC, the academic flagship hospital with Hackensack Meridian Health, is a large, complex tertiary/quaternary academic medical center. We have over 800 beds, just over 8000 team members here on campus and just under 2000 credentialed physicians. We have over 42,000 discharges a year, so we’re the busiest single admitting site within the state of New Jersey.

Q: What characteristics do you face with the communities you serve?

Mark Sparta: We sit in the most densely populated counties in New Jersey. In those counties, there’s over 3,000,000 residents, which is 1/3 of the population of the state. According to a recent census, New Jersey is the 7th most diverse state in in the nation.

Q: What role does HUMC play to serve this patient population?

Dr. Nicole Harris-Hollingsworth: We have an institutional commitment to diversity, equity and inclusion and institutional alignment and digital commitment for digital accessibility to enhance equity across a variety of spectrums including accessibility and income and language. Our ability to be able to provide resources that impact not only our patients and the communities that we serve but that are also team member accessible create a balance of equity that is not found in other places.

Mark Sparta: If we are going to be successful in our clinical outcomes and as an organization, we need to focus on having consistent health outcomes for all populations we serve, not just specific populations. I think that we’ve always had a culture of being sensitive to individual needs and compassionate care. Every time we provide care, we learn something more about another need within the community that we have to be able to support, whether it be for example, behavioral health or food insecurity. All the assessments that we do and referrals that we make unite us.

Q: What can you share with us about your DEI initiatives?

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Mark Sparta: We developed a DEI initiative, which really became paramount for us from the board level down through leadership to have compositions that are reflective of the communities that we serve. Unless someone has had the same life experiences or similar life experiences as others that they’re caring for, it’s hard to empathize with what they may be perceiving and relating to in terms of compassionate and culturally sensitive care.

That initiative was started several years ago with the Chief Diversity, Equity and Inclusion Officer appointment for the organization. I can tell you that HUMC has always been on this path without it really being a defined path. Bob Garrett, our CEO signed the Health Equity pledge and really endorsed this whole heartedly to be a strategic priority for the network. It’s one of our seven strategic priorities that has been adopted by the board and then endorsed by executive leadership and really drove down to individual sites.

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Dr. Nicole Harris-Hollingsworth: The emergency department teams are providing connections to community resources in over 152 languages. We have this integration of not just addressing social needs, but also addressing linguistic and standards of their class to make sure that we’re providing things that are done in an accessible way.
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Barry Pace: I put together a playbook for the nurses to understand more about disparities and equities and explain why they’re asking patients related questions during their assessments. This helped them feel more confident and comfortable when they went in the room to do their physical assessment. It was easy to get the buy in and then when I brought it to the rest of the managers, it helped them change part of the MBR process.

Q: Why did you decide to pursue Joint Commission HCE certification?

Dr. Chinwe Ogedegbe: Hackensack already had the culture of doing things like this. And then the program that Nicole brought to the hospital in 2019 was to screen elements across the entire network and that was really successful — 3,000,000 lives — a lot of screens done really well. And then my program was supported by the Department of Health, the COVID Equity Education Grant. So, all those programs were in existence. We felt we should demonstrate on paper what we’ve been doing for years.

Q: How did you prepare for certification?

Inia Estima: We reviewed the standards and did a gap analysis which involved all of our teams working on different pieces of the certification. Seeing that all come together was great. It included aspects that we had been working on as a network for many years. It was really a good transition to see that the Joint Commission standards reflected everything that we’ve been working towards. I think from a regulatory aspect that makes the Joint Commission HCE certification very different from their clinical certifications we’ve previously earned since it includes not only the patients’ perspectives and care that we offer them, but the team member component as well. We are seeing our team members’ perception of experience, of bias, of diversity and inclusion, etc.

Q: Can you tell us about your experience with the certification review?

Mark Sparta: When our Joint Commission reviewer arrived for the review, we could tell that he had done a lot of homework. He read our community health needs assessment that’s posted on our website. He was well prepared with a lot of great questions. The team provided a lot of different data cuts that we were able to show, where our investments were and what the payoffs were for our community.

Darryl Hughes: There was a moment when our reviewer approached a Spanish speaking patient and because he’s fluent in Spanish, he began to talk with him. But he was challenged by a frontline team member who asked if he was qualified to interpret for this patient. Our reviewer was very impressed that the team member asked him if he was the right person to be providing effective communication to a patient. That showed us our policies were being reinforced at the frontline and I think that was such an impressive takeaway for us to show that it is flowing through all levels of the organization.

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Q: What positive outcomes have you experienced?

Dr. Nicole Harris-Hollingsworth: It’s really about the notion of continuous improvement. You know the process of preparing for this certification made us look at how can we make things easier for patients. When I look at the process within a chart, we have the ability to identify some of the information that patients can prepopulate. We asked ourselves how could we begin to include some of the social needs and community resource accessibility utilizing that same format. This process inspired continuous improvement in other processes to allow us to provide a better experience for our patients and that’s the best kind of review, not where you’re trying to create something to make it great or to check a box. But when it really gives you an opportunity to look and say like, how do we continuously improve the system? We are in and it can be done in a way that doesn’t generate fear, but really inspires innovation.

Avonia Richardson-Miller: We have embraced the fact of health equity being a quality and safety issue and there’s been tremendous support from our quality team and from our digital technical services team. The data analytical tools that they have created provides the ability to slice and dice so much robust data.

Mark Sparta: I don’t think we were necessarily very data driven and our pursuit of Joint Commission HCE certification has really been shaped by being able to segment the scale of our data. When you talk about population health activities and trying to look at impactful data, we were well positioned to take advantage of the scale that we have and use our data to be able to implement actionable change.

Q: What would you like to share with other organizations considering Joint Commission HCE certification?

Dr. Chinwe Ogedegbe: The Joint Commission recorded webinars, review process guide and gap analysis template were great. Having leadership support and endorsement is key. Identifying a physician champion and a nurse champion was critical as well.

Dr. Nicole Harris-Hollingsworth: The experience of having the allied health and community element was really tremendous. This certification requires their full involvement, so to make sure that they were brought in led to wonderful things.

Avonia Richardson-Miller: We created health equity councils that have been launched at every site and are chaired by that site President. There are so many of the key stakeholders at the table that drive the decisions at that local level who really are responsible for integrating these incredible initiatives into the fabric of that local hospital site and replicated across and throughout our network. That solid governance structure has really provided a great framework of how our individual hospital sites are able to leverage the power of a great network behind them and all the great work that they’re doing to really be able to have the success that we’re seeing with this new certification.

Q: Would you like to share any final thoughts?

Peter Lomuscio: What’s great about certification is you build that chemistry with the team. We went through it together and it was just a tremendous journey for us. I’m proud that HUMC was the first to achieve Joint Commission HCE certification and I can’t wait to see our sister hospitals earn it as well!

Darryl Hughes: The network level of embedding health equity through all aspects of care and how we embrace this as a quality issue is great to see. A mentor of mine once said that if we focus on improving disparities and outcomes for all, all the boats float up and we’ve seen that impact.

Mark Sparta: We’ve used all of our Joint Commission certifications as a vehicle to not burden the team but to inspire and motivate them to continue to improve, to keep reaching for the stars. It almost forces the hand to have folks that wouldn’t typically work as closely with each other to align and work more closely, learn from each other, and make the whole process much more seamless. When you get those synergies from working together beyond your individual department at the end of the day, the patient wins because the outcomes are better because healthcare is a team sport, nobody does anything alone.


To learn more about the certification and to explore the Health Care Equity Certification Resource Center click the button below.

Learn moreLearn more about Health Care Equity Certification and the Resource Center