COALINGA REGIONAL MEDICAL CENTER
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.
No disparity data for this period.
2. Equity Plan
Identify Disparities
Stratify HCAHPS data by race/ethnicity, language, age, gender, insurance type, and unit.
Flag groups scoring =5–10 points below the hospital average.
Review patient comments to understand drivers of gaps.
Priority Domains
Focus improvement efforts on 2–3 areas with the largest disparities, typically:
Communication with Nurses
Communication with Doctors
Communication About Medications
Responsiveness of Staff
Care Transitions / Discharge Information
Patient & Community Engagement
Conduct listening sessions with affected patient groups.
Use diverse Patient and Family Advisory Councils (PFACs).
Incorporate community feedback into staff training and materials.
Strengthen Communication & Language Access
Ensure consistent use of qualified interpreters for LEP patients.
Develop multilingual discharge instructions and signage.
Implement teach-back for all education and document usage in EHR.
Provide cultural humility and communication skills training for staff.
Improve Care Transitions
Standardize discharge education using plain language and visual aids.
Provide care navigators or transitional nurses for high-risk patients.
Complete post-discharge follow-up within 24–72 hours.
Frontline Practice Improvements
Embed purposeful hourly rounding and bedside shift report.
Use whiteboards consistently for care plans and daily goals.
Introduce service recovery scripting for staff.
Staff Training & Accountability
Deliver training on implicit bias, trauma-informed care, and communication.
Share stratified HCAHPS data with units quarterly.
Identify unit-level “Equity & Experience Champions.”
Monitor & Report Progress
Metrics:
Quarterly stratified HCAHPS scores
Interpreter utilization rates
Teach-back compliance
Rounding audits
Report progress to unit leaders, quality committees, and PFACs. Celebrate teams that reduce gaps.
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 |
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.