DOCTORS 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.
| Measure | Stratification | Stratification Group | Stratification Group Rate | Reference Group | Reference Rate | Rate Ratio |
|---|---|---|---|---|---|---|
|
1.
AHRQ PSI surgical death rate
|
Age (excluding maternal measures) | 65 and older | 375.0% | 50 to 64 | 220.0% | 1.70 |
|
2.
AHRQ PSI surgical death rate
|
Expected Payor | Medicare | 373.8% | Medicaid | 232.1% | 1.60 |
|
3.
AHRQ PSI surgical death rate
|
Race and/or Ethnicity | White | 315.3% | Hispanic or Latino | 227.3% | 1.40 |
|
4.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | White | 87.7% | Hispanic or Latino | 73.3% | 1.20 |
|
5.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 89.1% | Female | 81.2% | 1.10 |
|
6.
AHRQ PSI surgical death rate
|
Sex Assigned at Birth | Female | 285.7% | Female | 285.7% | 1.00 |
2. Equity Plan
Hospital Equity Plan: Actions, Populations, Objectives, and Timeframe
All clinical and foundational goals are targeted for completion by December 31, 2027.
A. Clinical Safety (Addressing PSI 04 Death Rate Disparity)
-Population Impact: White, Male, Medicare patients aged 65 and older (the highest-risk surgical group).
-Measurable Objective: Reduce the PSI 04 Death Rate for this high-risk group by 10%.
-Key Actions: Implement universal screening and strictly enforce established protocols for the four at-risk groups. Update daily safety huddles and interdisciplinary rounds to ensure discussion of unique post-operative risks and cultural needs specific to these patients.
B. Effective Treatment (Addressing Pneumonia Mortality Disparity)
-Population Impact: White patients and Male patients.
-Measurable Objective: Reduce the Pneumonia Mortality Rate disparity for both White patients and Male patients by 10%.
-Key Actions: Enforce consistent clinical practice and improve adherence to standardized clinical pathways. Conduct an in-depth analysis of PSI-4 within the pneumonia stratum for White, male patients to evaluate variance and guide targeted education, standardization of early-rescue practices, and interdisciplinary interventions.
C. Person-Centered Care (Communication Gap)
-Population Impact: White patients aged 65-74 (HCAHPS communication gap).
-Measurable Objective: Achieve a 10% reduction in the HCAHPS communication gap for White patients aged 65-74.
-Key Actions: Standardize the discharge communication process for all high-risk surgical patients aged 65-74. This initiative will embed the "Teach-Back" method as a mandatory step to confirm the patient’s or caregiver's understanding of essential discharge information.
D. Care Coordination & Access to Care (Follow-up Barriers)
-Population Impact: Medicare patients aged 65 and older (Post-operative follow-up risk).
-Measurable Objective: Ensure successful completion of post-operative follow-up for Medicare patients aged 65 and older.
-Key Actions: (Shared with Person-Centered Care): Standardize the discharge communication process for high-risk surgical patients (65-74) by embedding the "Teach-Back" method to remove knowledge barriers, ensuring the patient fully understands how and when to access post-discharge services.
E. Addressing Social Drivers of Health (SDOH)
-Population Impact: Medicare patients aged 65 and older (Post-discharge safety and care continuity).
-Measurable Objective: Ensure 90% of Medicare patients aged 65 and older are successfully connected to resources.
-Key Actions: Conduct a standardized, validated SDOH screen on 100% of admitted patients through the electronic health record. Provide patients with comprehensive, localized resource materials based on identified needs.
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.