University Hospital’s Commitment to Health Care Equity: Identifying and Reducing Health Care Disparities

University Hospital (UH) is committed to delivering high-quality, equitable care to every patient we serve. As part of that commitment, we systematically collect, analyze, and act on patient demographic data to identify and reduce health care disparities in our community.

Data Collection

At the point of registration, UH collects self-identified race, ethnicity, and preferred written and spoken language directly from every patient or their legal guardian. Staff responsible for collecting this information receive training on best practices for gathering self-reported demographic data in a respectful and accurate manner.

Stratification and Disparity Identification

UH uses patient self-reported demographic data to stratify patient experience measures. In partnership with Press Ganey, UH analyzed HCAHPS patient experience data across Fiscal Years 2021, 2022, and 2023, stratified by self-identified race and ethnicity. This analysis identified meaningful and persistent disparities in the patient experience of Black or African American patients compared to the overall patient population, including in the following areas:

• Feeling informed about managing their own health after discharge (3.3 to 3.9 percentage points below the overall average)
• Feeling that hospital staff took their preferences into account during their care (4.1 to 5.3 percentage points below the overall average)
• Likelihood to recommend the hospital (1.7 to 6.6 percentage points below the overall average across three fiscal years)

Analysis of patient experience data also revealed disparities in communication-related domains among patients with limited English proficiency, including lower scores on measures of nurse and physician communication, medication explanation, and discharge preparation.

Actions Taken to Address Identified Disparities

Disparity #1: Race and Ethnicity — Opioid-Related Harm and Care Experience

In analyzing patient experience data stratified by race and ethnicity, University Hospital identified disparities in care outcomes and experience among Black and Latino patients, particularly in domains related to discharge preparedness, communication, and overall care coordination. These findings were consistent with broader community health data documented in UH’s 2022 Community Health Needs Assessment, which identified opioid use disorder and its disproportionate impact on Newark’s Black and Latino residents as a priority health equity concern.

In response, University Hospital developed and implemented a written action plan to address this disparity through the establishment of the Emergency Department Harm Reduction Center (HRC). The HRC action plan, funded through the New Jersey Department of Human Services Division of Addiction Services Opioid Expansion Grant, outlines a phased, multi-year strategy to deliver equitable, patient-centered harm reduction services, including naloxone distribution, medication-assisted treatment navigation, and community health worker support, to inpatient and ED populations experiencing the greatest burden of opioid-related harm. The HRC represents UH’s direct, documented response to health care disparities identified through the analysis of patient self-reported demographic data, and progress is reviewed regularly by hospital leadership and reported to the Board of Directors.

Disparity #2: Language Access — Communication and Discharge Preparation

In response to identified disparities in communication-related domains among patients with limited English proficiency, University Hospital developed and maintains a written Language Access Plan in accordance with Title VI of the Civil Rights Act, National CLAS Standards, and CMS Conditions of Participation. The Language Access Plan describes UH’s systematic approach to ensuring equitable access to care for patients with limited English proficiency and those who are deaf or hard of hearing, including the provision of qualified medical interpreters, translated written materials, and multilingual signage. Language access services are monitored for quality and utilization, and the Language Access Plan is reviewed and updated regularly to reflect the evolving linguistic needs of UH’s patient population.

Additionally, UH has taken the following system-wide steps to address disparities across both populations:

• Launched structured training on culturally responsive care for clinical and patient-facing staff, aimed at reducing gaps in patient-reported measures of courtesy, personalized care, and responsiveness
• Developed a Community Health Improvement Plan (CHIP) grounded in the findings of UH’s 2022 Community Health Needs Assessment, with targeted action plans addressing the social determinants of health that drive disparate outcomes in Newark’s most vulnerable communities

Board Accountability

UH’s Division of Human Experience & Population Health reports regularly to hospital leadership and the Board of Directors on progress toward reducing health care disparities and advancing health equity across the institution. Health equity performance, including progress on the initiatives described above, is a standing agenda item in executive leadership review.

Contact

For questions about University Hospital’s health equity work, please contact the Division of Human Experience at 973-561-7307.