Hospital Equity Measures Reporting Program

Overview#

Assembly Bill 1204 (Chapter 751, Statutes of 2021) requires the Department of Health Care Access and Information (HCAI) to develop and administer a hospital equity report program to collect and post hospital equity reports. These annual reports are required to include measures on patient access, quality, and outcomes by race, ethnicity, language, disability status, sexual orientation, gender identity, and payor as recommended by the Hospital Equity Measures Advisory Committee (Advisory Committee). The reports are also required to include a plan to prioritize and address disparities for vulnerable populations identified in the data and as specified by the Advisory Committee.

Upcoming Activities#

The Hospital Equity Measures Reporting Program Fact Sheet includes program activities through October 2025.

Read the full Hospital Equity Measures Reporting Program Fact Sheet.

2022 – JANUARY TO DECEMBER#

• Began program planning
• Convened Hospital Equity Measures Advisory Committee
• Conducted meetings with Hospital Equity Measures Advisory Committee
• Developed and published first set of committee recommendations

2023 – JANUARY TO DECEMBER#

• Begin rulemaking process**
• Continue meeting with Hospital Equity Measures Advisory Committee

2024 – JANUARY TO DECEMBER#

• Complete rulemaking process to establish regulations to specify reporting requirements
• Begin outreach to hospitals to prepare for first annual submission
• Continue meeting with Hospital Equity Measures Advisory Committee

2025 – JANUARY TO OCTOBER#

• Provide technical assistance to hospitals in the development of first annual hospital equity reports
• Submission of first equity reports by hospitals due September 30, 2025*
• Continue meeting with Hospital Equity Measures Advisory Committee

** HCAI will engage in a separate rulemaking process to implement the revisions to the definition of
“vulnerable populations” as it relates to the community benefit planning program.

Hospital Equity Measures Advisory Committee#

The Advisory Committee will be comprised of health care stakeholder experts, including a health care quality and measurement expert, and will:

1. Make recommendation to assist and advise the HCAI director on the appropriate measures that hospitals are required to report in their annual equity reports. These measures should also align with the health equity measures developed by the federal Centers for Medicare and Medicaid Services and include any relevant Agency for Healthcare Research and Quality’s Quality Indicators. Once finalized the recommendations will be published on the HCAI website.
2. Advise the HCAI director in identifying the 10 widest disparities in health care quality for vulnerable populations, in terms of access or outcome and priority performance areas to be addressed in the health equity plan that hospitals are required to include in their annual equity reports. The committee will also provide recommendations on the measurable objectives and specific timeframes in which disparities for vulnerable populations identified in the data need to be addressed
3. Once reports have been submitted, the Advisory Committee will need to make recommendations to the department regarding the submitted hospitals’ health equity plans.  Once finalized these recommendations will be published on the HCAI website.
4. Through its meetings, provide a forum for stakeholder and public engagement.

2022 Advisory Committee Measures Recommendations#

HCAI will consider the Advisory Committee’s recommendations in establishing the hospital equity measures for reporting by licensed general acute care hospitals, acute psychiatric hospitals, specialty hospitals, and hospital systems with at least two general acute care hospitals in California. Given the diverse services provided by hospitals throughout California that are dependent upon local population health needs, the Committee agreed to organize its recommendations for into the following four areas:

• Structural measures for all hospitals: The Advisory Committee recommended 9 structural measures for all hospitals to include in the hospital equity reports.
• Core quality measures for all hospitals: The Advisory Committee recommended 11 quality measures for all general acute care hospitals to include in their hospital equity reports.
• Core quality measures for acute psychiatric hospitals: The Advisory Committee recommended 8 quality measures for psychiatric hospitals to include in their hospital equity reports.
• Core quality measures for children’s hospitals: The Advisory Committee recommended 6 quality measures for children’s hospitals to include in their hospital equity reports.

Follow the hyperlink to review the 2022 Advisory Committee Hospital Equity Measures Recommendations

Additional Resources#

• Medical Equity Disclosure Act: Health & Safety Code sections 127370 et seq.
• Executive Order: Advancing Racial Equity and Support for Underserved Communities Through the Federal Government
• Office of Minority Health, CMS Equity Initiatives.
• Agency for Healthcare Research and Quality, Quality Indicator Resources.

Contact#

For questions or inquiries about the Hospital Equity Measures Reporting Program, you may email hospitalequity@hcai.ca.gov.

To receive meeting notices for the Hospital Equity Measures Reporting Program, subscribe here.