COLUSA 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
HCAHPS: Received Information - Race Disparities
Colusa Medical Center has a generally homogenous patient population; of our 77 HCAHPS responses, only 8 were non-white, and all 8 of these responses defined themselves as American Indian/Alaskan Native. Nonetheless, analysis demonstrated disparities among responses related to receiving information in a clinical setting. Only 25% of AIAN respondents attested "Yes" to the question, "I received information about symptoms and problems to look for", as compared to 54% of white respondents. In this vein, there were additional disparities related to staff communication: 87.5% of AIAN respondents reported that staff "Never" described medication side effects as opposed to 41.9% of white respondents; this is especially concerning, since AIAN respondents reported a 100% rate of taking new medications as compared to 71% of white respondents.
Colusa Medical Center acknowledges these disparities. We are currently developing a focused process improvement project related to HCAHPS measures. Staff communication with patients will be a key component of this project; and in recognition of the disparities identified through our Equity Measures Report, we will include a robust equity component to this project: with focused improvements in communicating with diverse patients.
HCAHPS: Received Information - Age Disparities
The nominal HCAHPS respondent at Colusa Medical Center is aged 65+. Patients aged 65+ reported generally good communication results: with 69.5% asserting that "Yes", they did receive satisfactory information about symptoms and problems to look out for. However, slightly younger respondents aged 50-64 had far worse rates, with only 12.5% responding "Yes" to receiving satisfactory information.
This is an unusual finding. Patients aged 50-64 also reported very low satisfaction with doctor-provided information (with 82.3% reporting scores of 1-25/100 on this measure, as compared to only 8.4% of patients aged 65+). This indicates general difficulties in communicating with this population.
It is possible that this finding is an artifact of other demographic intersections. The respondent population aged 50-64 was far more likely to be AIAN than respondents aged 65+ (35.29%, vs. 3.3%); in addition, they were more likely to be high school educated (70.59%, vs. 20.34%) , as opposed to college-educated (11.76%, vs. 22.0%).
Colusa Medical Center acknowledges this disparity. To best address this disparity, we will conduct further analysis on our patient population to determine the root cause of the low scores reported by patients aged 50-64. This will include an analysis of the intersections previously discussed. The goal of this analysis will be to review communication procedures, and to include additional guidelines for patients determined to be high-risk.
In addition, we are currently developing a set of performance improvement projects related to CMS's Age-Friendly Care guidelines. Though this set of guidelines is only explicitly stated to be for patients aged 65+, if our intersectional analysis determines that the age range of 50-64 (rather than another demographic category) does in fact predict hospital outcomes more effectively than any other category, we will expand our Age-friendly Care program to include all patients aged 50+.
HCAHPS Would Recommend - Age Disparities
Related to the issues in communication, HCAHPS respondents aged 50-64 reported lower likelihoods of recommending our facility (53.0% vs 66.2%). This distinction, however, comes mostly from the "Definitely No" response: 11.8% of respondents aged 50-64 reported this score, as compared to only 1.7% of respondents aged 65+.
As a related figure: respondents aged 50-64 reported a lower overall satisfaction in complaint resolution, with 100% of their satisfaction scores falling within the middle "50" band. Patients aged 65+, by comparison, rated their satisfaction in complaint resolution in this "50" band or lower only 44.3% of the time--rating satisfaction in the upper "75" and "100" bands over the remainder of the time.
There is a likely relationship between the low satisfaction with complaint resolution and the likelihood of recommending our facility for this patient population. Colusa Medical Center has recently hired new quality department staff to address and resolve complaints, and is looking to improve its complaint and peer/department review process on an ongoing basis.
HCAHPS Would Recommend - Race Disparities
Race disparities in likelihood to recommend this facility indicate that although AIAN respondents received less clarity regarding their stay--they were nonetheless more likely to recommend the hospital than white respondents, with 87.5% asserting to recommend the facility, as compared to 43.4%. To improve patient satisfaction with care among the general population, any successful project trialed with a stratified population will be instated among all patients (if appropriate).
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 |
No |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
No |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
No |
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information |
No |
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 |
No |
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 |
No |
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 |
No |
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.