FAIRCHILD 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.
HCAHPS survey-received information
|
Race and/or Ethnicity | American Indian or Alaska Native | 82.3% | White | 86.4% | 1.10 |
2. Equity Plan
This health report will provide our Health Equity Taskforce with clear directive over what to focus on moving forward. Fairchild Medical Center is committed to identifying and addressing the primary disparities patients face in our communities through our internal equity analysis and patient safety data. Our approach is designed to combine governance, data-driven interventions, and continuous monitoring to ensure measurable improvements in health outcomes across diverse populations.
Fairchild Medical Center established its Health Equity Taskforce (HET) in 2024. The HET serves as the central body for equity-focused initiatives and is designed to ensure that equity focused care is interwoven into all services throughout the organization.
The HET represents a diverse and multidisciplinary team throughout the organization, including administration, nursing administration, medical staff and providers, quality and patient safety, and more. The Health Equity Officer of Partnership HealthPlan of California is also a regular attendee of the HET and provides crucial information to Fairchild Medical Center.
The HET mandate includes the following:
Identifying and prioritizing disparities:
The HET strives to use stratified data, including but not limited to race, ethnicity, age, social determinants of health (SDOH), and English Language Proficiency, to identify and address key care gaps.
Developing targeted interventions:
High-impact areas, such as NTSV Cesarean Section rates, access to stroke care and education, and outpatient behavioral health access are some of the areas that the HET identified.
Engaging clinical teams:
Education on best practices and soliciting feedback from internal and external stakeholders was key to the HET’s focus.
Monitoring progress:
Disseminating stratified data to leadership and frontline teams for transparency and accountability was imperative. The taskforce meets monthly and reports regularly to senior administration, ensuring alignment with organizational QAPI principles.
Fairchild Medical Center’s electronic medical record (EMR), EPIC, is a cornerstone of this plan. Current capabilities enable the HET to track trends in age, gender, race, ethnicity, and other socioeconomic factors. Enhancements are also underway to expand demographic information entry at registration to include race, ethnicity, SDOH indicators, and primary language spoken. This will enable patient safety and clinical outcomes data to be stratified. The HET strives to integrate dashboards for real-time monitoring of disparities and to trigger alerts for suspected inequities. These EPIC enhancements will enable Fairchild Medical Center to link data to action plans, enabling rapid-cycle improvement and targeted outreach for vulnerable populations.
The HET also seeks to align Fairchild Medical Center’s focus with the results of the Community Needs Health Assessment. The CHNA prioritized health needs based on community input, quantitative data, and equity considerations. The ten most pressing disparities were:
Access to Primary Care and Specialty Care
Behavioral Health Services
Substance Use Disorder (SUD) Treatment
Transportation Barriers
Food Insecurity
Housing Instability and Homelessness
Chronic Disease Management
Maternal and Child Health
Workforce Shortages
Social Determinants of Health
The HET reviews these disparities regularly and focuses on utilizing data to better understand what interventions can be effective. Among these disparities, the following actions were taken by the HET that will continue through 2025.
Understanding NTSV Cesarean Section Rates
Fairchild Medical Center experienced a higher-than-average NTSV Cesarean Section Rate in 2024. The HET engaged internal stakeholders to understand the contributing factors to this event, and it was determined that the impact was not limited to any specific socioeconomic groups. This focus and priority of understanding these rates will continue in 2025.
Access to Stroke Care and Education
Inpatient admissions for stroke were reviewed regularly by the HET to review trends with age, geographic proximity to hospital, race, ethnicity, gender, and more. While no disparities were highlighted by the data, it was determined that there was little data for patients whose primary language is Hmong and Spanish. In Q4 of 2024, the HET coordinated with the Stroke Coordinator to develop educational materials that could be shared with Siskiyou County Public Health and taken to patients who spoke these languages.
Outpatient Behavioral Health
The HET determined that despite representing a significant percentage of the community in Siskiyou County, the number of people aged 65 and older being treated for behavioral health in the outpatient clinics was not consistent with the total population. The goal was established to develop a senior-specific behavioral health service line, Senior Lif
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 |
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.