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

Recently, Hackensack University Medical Center (HUMC) in New Jersey became the first in the nation to achieve The Joint Commission’s Advanced Certification in Perinatal Care (ACPC). This advanced certification is offered in collaboration with the American College of Obstetricians and Gynecologists (ACOG). ACPC helps organizations address the growing need for appropriate obstetric care given the challenges of increasing maternal morbidity and mortality in the United States.

Participating interviewees included:

  • Renee Harvey, Vice President, Regulatory Affairs at Hackensack Meridian Health
  • Elizabeth Polanco, Administrative Director at Hackensack Meridian Health
  • Jennifer Kopelman, Nurse Manager of Labor and Delivery at Hackensack University Medical Center
  • Kara Hennessy, OB Education Specialist at Hackensack University Medical Center
  • Inia Estima, Director, Regulatory Affairs at Hackensack Meridian Health
  • Peter Lomuscio, Regulatory Manager at Hackensack University Medical Center
,,When we were preparing for ACPC, our regulatory team said if the reviewer has findings, we’re going to take that and use it as a positive. How can we make ourselves better going forward, how can we make it better and safer for our patients? We never went into this thinking that we hope they don’t find anything. It was the opposite. It was like, bring it on.,,

Inia Estima - Director, Regulatory Affairs - Hackensack Meridian Health

Q: What kind of provider organization is Hackensack University Medical Center?

Elizabeth Polanco: As the largest of 18 hospitals in the system, we are considered the flagship hospital. On average we deliver over 5,000 babies a year, the most out of any in our system. We have 50 inpatient beds, and 16 beds in labor and delivery. There is a six-bed triage area, and a very robust postpartum unit and high-risk unit as well.

We cover the span of New Jersey, from north to south. Our demographics are very diverse. The population we serve is approximately 33% white and then the rest of the groups are divided pretty equally between Latino and African American.

Q: Why did Hackensack University Medical Center decide to seek ACPC?

Jennifer Kopelman: Once I heard about ACPC, I knew we had the ability to earn the certification. There was a lot of work that had to be completed behind the scenes to put it all together, but the foundational parts were already there. In many ways, we were already working towards certification back in 2017, when we had a voluntary review of our program through the ACOG. After this very transparent review, we worked hard to make extreme quality and safety improvements within our obstetric service.

We started the Perinatal Quality and Safety Committee after that voluntary review. We were meeting every week as an interdisciplinary team, focusing on perinatal core measures as well as all the Elements of Performance to make sure we were meeting or exceeding what was set out by our regulatory departments, as well as what our patients need. Honestly, this really feels like a culmination of dreaming and working toward something for a long time.

Q: What were some of your challenges and how were they addressed?

Elizabeth Polanco: I think coming together and sharing the vision is more difficult than folks may think. Bringing the entire team together proved to be a little bit of a challenge: sharing the vision and getting the buy-in. This kind of accomplishment is not a one-person activity. Doing the convincing work was a challenging task.

Jennifer Kopelman: The partnership between the clinical team and the regulatory team was the most important factor in the pursuit of ACPC.

Elizabeth Polanco: The team did make magic. That collaboration really helped in bringing the rest of the team along — our physician partners and our other ancillary services — because they knew that we had our regulatory partners here with us who were going to guide us.

Q: What are some of the outcomes highlighted by the certification process?

Icon of a pregnant woman.
Elizabeth Polanco: We reduced unwanted variations in care, established evidence based practice and protocols and standardized not only our policies and our protocols, but also our education. Now everyone is speaking the same language, and we know that the data shows that when you reduce variation, you improve outcomes. We’ve reduced our NTSV rate to 19% — a consistent drop by 50% over a five-year period. We have standardized education not only for nurses but for providers and everyone that touches our patients. We have educated everyone in very similar ways and with standardized tools, and we have the data to back it up.
Three figures around lightbulb icon
Peter Lomuscio: We raise the level of care that we provide to our patients. We drill down on specific metrics, and it increases buy-in when we see positive outcomes. There’s immense value to being involved in the regulatory process and seeing all the hard work pay off. Our team has been doing this level of work for years. It was just a matter of putting it on paper and demonstrating it to everyone.
Opened book icon
Jennifer Kopelman: You can institute all the policies and protocols that you want, but at the end of the day you need your team members to believe in them, follow them, and have the education necessary to implement them.
Three doctors icon
Kara Hennessy: The team here is very fortunate to have so much support from the nursing leadership, the OB Department and the Clinical Education Department. We offer an enormous amount of education to our team, whether it be in-person education or independent learning.
Handshake icon
Jennifer Kopelman: I feel like it really does start from the top. While there is a lot of decision-making from the middle out, having leadership support — whether it’s local leadership or network leadership — is vital to program success.

Q: How did the certification process impact the way you look at organizational improvement?

Elizabeth Polanco: This is the first time I’ve had the privilege of leading a team that understands, on every level, how regulatory standards affect their daily work. If you speak to the labor and delivery team, to the postpartum team, to the high-risk team, they understand about early-term deliveries before 39 weeks. They understand what the impact is in their everyday work, and that’s remarkable because that’s how you improve care. That’s how you improve efficiencies and change outcomes. That’s also how you also render care at lower cost.
Inia Estima: When we were preparing for ACPC, our regulatory team said, if the reviewer has findings, we’re going to take that and use it as a positive. How can we make ourselves better going forward, how can we make it better and safer for our patients? We never went into this thinking I hope they don’t find anything. It was the opposite. It was like, bring it on.
A pregnant Latina woman speaks to a black female doctor.
A pregnant Asian woman speaks to a doctor.
Two doctors hand a freshly delivered baby to its parents.
A pregnant black woman receives an ultrasound.

Q: How was your experience working with The Joint Commission?

Renee Harvey: HUMC has 30 disease-specific and advanced care programs. So, we’re very familiar with The Joint Commission and the review process. We know that The Joint Commission has done a great job with our organization. They send people who know what they’re doing, who usually practice in the area that’s being reviewed on a regular basis. I can only say tremendously positive things about The Joint Commission and the review process because they entertained our questions and collaborated with us.

Elizabeth Polanco: From a clinical perspective, I can describe the three-day review as having run three marathons in three days. I have to say that it was nothing but positive, because I think that the team came in with an open mindset of, “we’re going to learn from this.” Our reviewers were relentless in their pursuit of trying to see what our program was about, and to make sure that what we were showing them was accurate. It was a positive experience, and a learning opportunity for all of us.

Jennifer Kopelman: This was a great way for us to say, “We’ve invited The Joint Commission here, and we want to showcase what we do. This is our time to shine. This is our time to partner with them.” If anything, this process fostered that joint partnership of our clinical teams with The Joint Commission. No one is looking to fail anybody. No one is looking to get someone in trouble. We’re both looking to utilize each other’s expertise and collaborate, in order to make ourselves better for our patients.

,,We know that the data shows that when you reduce variation, you improve outcomes. We’ve reduced our NTSV rate to 19% — a consistent drop by 50% over a five-year period.,,

Elizabeth Polanco - Administrative Director - Hackensack Meridian Health

Q: What advice would you give an organization who is thinking about taking this road to certification?

Renee Harvey: Get a hold of Joint Commission standards and do a gap analysis, a very detailed one — cross for cross, piece for piece — because it is very specific and very challenging. Get a copy of the Review Process Guide and the agenda because there’s additional information in there with regards to some specific tracers. Review the evidence-based clinical practice guidelines. Make sure to have a physician champion — or two or three — who’s going to lead from a medical perspective, and make sure to have RN champions.

Elizabeth Polanco: Don’t shy away from showing what your team has in place. Do your gap analysis, rally your team and go forward together. It’s a good learning experience.

Jennifer Kopelman: I think the review reinvigorates people to keep getting better. Keep up the relentless pursuit of knowledge and education to best serve your community.


For more information about ACPC, visit the Joint Commission ACPC web page.

Learn more Go to the ACPC web page