CHINESE HOSPITAL
1. Top 10 Disparities
The following table lists the ten largest health equity disparities identified for this reporting period.
Disparities for each hospital equity measure are identified by comparing the rate ratios by stratification groups. Rate ratios are calculated differently for measures with preferred low rates and those with preferred high rates. Rate ratios are calculated after applying the California Health and Human Services Agency's "Data De-Identification Guidelines (DDG)," dated September 23, 2016.
The table below highlights the ten widest health equity disparities identified by hospitals and hospital systems during this reporting period. Measure names have been shortened for display purposes. To view each measure in full, please download the complete Hospital Equity Report using the link below.
| Measure | Stratification | Stratification Group | Stratification Group Rate | Reference Group | Reference Rate | Rate Ratio |
|---|---|---|---|---|---|---|
|
1.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 9.8% | Male | 7.8% | 1.30 |
2. Equity Plan
Health disparity is a measurable difference in health outcomes, access, or quality of care among distinct population groups resulting from social, economic, or environmental disadvantages. An Equity Plan is a strategic set of actions intended to identify, address, and reduce health disparities among a hospital’s patient population, including measurable objectives and accountability structures.
Given the Hospital's small facility size and outcome distribution, analysis identified a single statistically significant health disparity: female patients aged 65 and older experienced higher all-cause 30-day unplanned hospital readmission rates at 9.6%, compared to 7.8% for male patients. As a result, addressing the readmission gap for older women is our explicit Disparity Improvement priority for 2025.
All equity plan objectives are defined with reference to health disparity as measured in stratified outcome rates.
Action Plan:
• Root Cause Analysis & Data Stratification:
Review records and case mix index by age, gender, Social Determinants of Health (SDOH), and language preference. Focus on intersectional risks for older women.
• Universal SDOH Screening:
Expand screening at discharge and follow-up for all older women, prioritizing social support, housing, food security, and language needs.
• Enhanced Discharge and Follow-Up:
Standardize multi-lingual, culturally tailored discharge education for all women 65+, deliver timely follow-up calls (with or without language interpreter), and involve families/caregivers.
• Navigator & Community Resource Engagement:
Assign patient experience team to include high-risk female discharge concerns to their rounding priorities. Leverage health plan and community resources to address gaps such as but not limited to, insurance, navigation, transportation, food, and social connection.
• Monitor and Report:
Use stratified dashboards to report ongoing progress. Incorporate SDOH and structural data into Quality Improvement meetings with executive and governing body leadership. Identify gaps for improvement and make decisions aimed at enhancing patient care.
• Just Culture Commitment:
Foster a supportive environment for staff to report safety/quality events, centering system learning and accountability over blame, especially in situations that may impact discharge support and follow-up care.
• Measurable Objectives:
15% reduction in 30-day readmission rates for women 65+ within 12 months; >80% SDOH documentation rate for this group; 90% (stretch goal of 100%) multi-lingual follow-up call rate after discharge.
3. Structural Measures
| Centers for Medicare & Medicaid Services (CMS) Hospital Commitment to Health Equity Structural (HCHE) Measure | Yes/No |
|---|---|
Our hospital system strategic plan identifies priority populations who currently experience health disparities |
Yes |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
Yes |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
Yes |
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information |
Yes |
Our hospital system inputs demographic and/or social determinant of health information collected from patients into structured, interoperable data elements using a certified EHR technology |
Yes |
Our hospital system stratifies key performance indicators by demographic and/or social determinants of health variables to identify equity gaps and includes this information in hospital performance dashboards |
Yes |
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews key performance indicators stratified by demographic and/or social factors |
Yes |
4. Web Address for Equity Report
5. Download Equity Measures Report
Click on the link below to download the equity measures report.
Click on the link below to download all equity measures reports.