Hospital Equity Measures Reporting Program

Overview#

Health and Safety Code Sections 127370-127376 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.

Laws and Regulations#

• Health and Safety Code Sections 127370-127376
• California Code of Regulations Title 22,Sections 95300-95316
  • Documents incorporated by reference:
    • Measure Submission Guide
    • Methodology for Calculating All Cause, Unplanned, 30-Day Hospital readmission Rate, California Department of Health Care Access and Information.
    • Department’s Format and File Specification for Submission of the Hospital Equity Report, Version 3.1(Excel) (Word)
    • The California Health and Human Services Agency’s ‘Data De-Identification Guidelines (DDG),’ Version 1.0

Submit Hospital Equity Measures Reports#

In accordance with California Code of Regulations (CCR) Title 22, Section 95308, Hospital Equity measures Reports must be submitted annually, by September 30, in the Hospital Disclosures and Compliance (HDC) System. Report submitters must register through the HDC System. The instructions for creating an account and associating with a facility can be located in the QuickStart Guide – Getting Started. Additional information can be located in the HDC System and Hospital Equity Measures Report Resource Manual, listed under the Reporting Resources section below.

Hospital Equity Measures Reports must be submitted via the HDC System using one of the following methods:

• Manually entering the required reporting information online.
• Uploading comma-separated value (.csv) files containing all required information for one or more hospital plan(s). These files shall comply with the format and file specifications outlined on the Hospital Equity Measures Reporting Excel Template.

Request an Extension#

Health and Safety Code Section 127374 Subsection (b), authorizes HCAI to grant a single 60-day extension, per report year, to file the Hospital Equity Measures Report. In accordance with CCR Title 22, Section 95307, extension requests must be requested via the Hospital Disclosures and Compliance (HDC) Report Submission Portal. Steps on how to complete this task can be found in the QuickStart Guide-Requesting an Extension. Additional information can be located in the HDC System and Hospital Equity Measures Report Resource Manual, listed under the Reporting Resources section below.

Late Submission#

CCR Title 22, Section 95309 authorizes HCAI to impose a civil fine of one hundred dollars ($100) per day, and up to a maximum of five thousand dollars ($5,000) for failure to file a timely report.  Fines imposed may be appealed pursuant to current appeals processes described in CCR Title 22, Sections 95311-95316.

Reporting Resources#

• 2024 List of Required Hospitals for Hospital Equity Measures Report Submission
• Hospital Equity Measures Reporting FAQs (Coming soon!)
• Measure Submission Guide
• Methodology for Calculating All Cause, Unplanned, 30-Day Hospital readmission Rate, California Department of Health Care Access and Information.
• The California Health and Human Services Agency’s ‘Data De-Identification Guidelines (DDG),’ Version 1.0
• Manuals/Guides
  • HDC System/Hospital Equity Measures Reporting Resource Manual (Coming soon!)
  • QuickStart Guide Series:
    • Getting Started
    • Approving Another User for a Facility
    • Requesting for a Report Extension
    • Starting a New Report
    • Revising a Submitted Report (Coming soon!)
• Hospital Equity Measures Reporting, Excel Files: (coming soon!)
  • General Acute Care Hospital
  • Children’s Hospital
  • Acute Psychiatric Hospital
  • System Level Report

Hospital Equity Data Toolkit#

HCAI has developed a Hospital Equity Data Toolkit, a collection of resources for hospitals that outline best practices to enhance demographic healthcare quality data collection, analysis, reporting and equity planning. This collection of resources was developed in collaboration with the Hospital Equity Measures Advisory Committee. The page and resources are an evolving curation, intending to be informative and updated regularly.

Click the button to view the Hospital Equity Data Toolkit.

Additional Resources#

• Office of Minority Health, CMS Equity Initiatives.
• Agency for Healthcare Research and Quality, Quality Indicator Resources.

Hospital Equity Measures Reports and Data Products (Coming soon!)#

All previously submitted Hospital Equity Measures Reports can be accessed using the links below. The information contained in the Hospital’s Equity Measures Report is provided for informational purposes only.

All Previously Submitted Plans (coming soon!)

All previously submitted Hospital Equity Measures Reports are available on our Open Data Portal (ODP). You will find datasets for all years beginning with 2024 reporting year.

• Open Data Portal (ODP)

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.

2025 – January to December#

• Complete rulemaking process to establish regulations to specify reporting requirements.
• Begin outreach to hospitals to prepare for first annual submission.
• 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

2026- January to June#

• 2024 Reporting Period closes.
• Complete review of Hospital Equity Measures Reports.
• Continue meeting with Hospital Equity Measures Advisory Committee.
• Prepare for 2025 Report Collection.

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

Contact#

For all inquiries related to the Hospital Equity Measures Reporting Program, please contact us via email at hospitalequity@hcai.ca.gov or via phone at (916) 326-3830. The Hospital Equity Measures Reporting inbox is supported Monday – Friday 8:00 a.m. to 5:00 p.m. PST, excluding State of California observed holidays.

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