EMANATE HEALTH QUEEN OF THE VALLEY 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
|
Age (excluding maternal measures) | 50 to 64 | 16.9% | 18 to 34 | 4.9% | 3.40 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.5% | 18 to 34 | 4.9% | 2.90 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.6% | Private | 5.6% | 2.80 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 9.6% | 18 to 34 | 4.9% | 1.90 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 10.5% | Private | 5.6% | 1.90 |
|
6.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 14.5% | Female | 8.7% | 1.70 |
|
7.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 15.1% | Female | 9.4% | 1.60 |
|
8.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Female | 90.5% | Male | 56.7% | 1.60 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 15.1% | Hispanic or Latino | 10.5% | 1.40 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 15.0% | Hispanic or Latino | 10.5% | 1.40 |
2. Equity Plan
Emanate Health is committed to reducing readmission rates especially for populations experiencing health disparities. Of the top ten disparities identified for Emanate Health Queen of the Valley Hospital (QVH), nine are related to readmissions. Patients aged 35 and greater readmit at a greater frequency than the reference group of patients less than 35 years of age. White and Black patients have a higher readmission rate than the Hispanic reference group. Males and males with a behavioral health diagnosis readmit at a higher rate than Females. Finally, patients with federal health insurance have a higher readmission rate than the private pay reference group. In an effort to close this gap, Emanate Health is building a program that concurrently manages patients with identified disparities in-house and following-up with post-discharge education and follow up. Reducing avoidable 30-day readmissions among this population requires a coordinated, multidisciplinary approach that emphasizes risk identification, transitional care, and engagement with community facilities. The readmission reduction program is part of the quality assessment and performance improvement plan. Using a data-driven approach, readmissions for patients with disparities are evaluated for trends and opportunities for improvement. Rapid cycle improvement models along with Robust Process Improvement tools and methods are used to develop action plans and deliver results. The goal of this scope of work is to reduce 30-day hospital readmission rates for patients who are managed by the readmission reduction program by ten percent within two years of program implementation.
In addition, pneumonia remains one of the leading causes of hospitalization and mortality in the United States, especially among older adults and patients with multiple comorbidities. At QVH, female patients show an increased 30-day pneumonia mortality rate when compared to the male reference group. Pneumonia mortality rates are evaluated as part of the organizations quality assessment and performance improvement plan. Ongoing pneumonia and sepsis mortality improvement work is conducted by a multi-disciplinary team consisting of representatives from the medical staff, pharmacy, nursing, infection control, the emergency department, and performance improvement. Using a data-driven approach, mortalities are evaluated for trends and opportunities for reduction. Rapid cycle improvement models along with Robust Process Improvement tools and methods are used to develop action plans and deliver results. The primary goal is to decrease avoidable female pneumonia 30-day mortalities by five percent over the next year.
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.