FRENCH HOSPITAL 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.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 12.0% | 18 to 34 | 2.9% | 4.10 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 9.1% | 18 to 34 | 2.9% | 3.10 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 5.7% | 18 to 34 | 2.9% | 1.90 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 9.7% | Private | 5.9% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 9.1% | Private | 5.9% | 1.60 |
|
6.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 9.9% | Female | 6.9% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 9.5% | White | 8.5% | 1.10 |
2. Equity Plan
Health Equity Planned Actions to Address Identified Top Disparities:
To understand why the identified populations are having increased readmissions there needs to be additional information to help identify the "why" related to these readmissions to assist in creating a meaningful intervention. Each of the actions planned below address person centered care, patient safety, social drivers of health, effective treatment, care coordination and access to care.
Actions Planned:
1. Gain better understanding around the "why" of readmissions and barriers to health:
a. Specific: By October 31, 2025, Care Coordination will consistently assess, document, and track the causes of readmissions (from social determinants to effective care concerns), reporting qualitative and quantitative data weekly at the Hospital Safety Huddle and monthly at the Clinical Excellence Committee.
b. Measurable: Data on readmission causes will be collected and reported.
c. Achievable: Care Coordination currently assesses and reports; this goal formalizes and refines the reporting frequency and venues.
d. Relevant: This directly contributes to understanding and addressing readmission drivers.
e. Time-bound: By October 31, 2025.
2. Multidisciplinary assessment of data and development of health disparity plans around readmissions:
a. Specific: By December 31, 2025, a multidisciplinary team at the Clinical Excellence Committee will implement a monthly review process for readmission data, creating, implementing, and evaluating interventions to reduce readmissions.
b. Measurable: Interventions created, implemented, and evaluated monthly; readmission rates will be tracked (PDSA model).
c. Achievable: This builds on existing data review and intervention processes.
d. Relevant: Directly addresses top health care disparities outcome of readmissions.
e. Time-bound: By December 31, 2025 (for process establishment), with bi-monthly evaluation ongoing.
f. Time-bound: February 2026 (session), March 15, 2026 (data review), April 15, 2026 (intervention implementation).
3. Review other data sources, such as event reports and patient experience data, to assess health disparities:
a. Specific: By December 31, 2025, event reports and patient experience data will be assessed annually to identify causes related to health disparities, specifically language, culture, and ethnicity, to inform disparity reduction efforts.
b. Measurable: Annual assessment completed, with findings documented.
c. Achievable: For the event reports, this is an existing annual process that can be focused on health disparities. For patient experience data this is a new process with agreement between patient experience leader and health disparity leader to meet quarterly to start looking at the data through a disparity lens.
d. Relevant: Helps identify underlying causes of health disparities through untapped data resources.
e. Time-bound: By December 31, 2026 (for the annual assessment).
4. Communication of health disparity identification data, actions put in place and evaluation of interventions to leaders within the hospital: will be reported to the Senior Leadership Team at the Monthly Quality meeting. Additionally this information will be shared at the all manager Quality Meeting quarterly.
a. Specific: By October 31, 2026, health disparity data, implemented actions, and evaluation outcomes will be consistently reported to the Senior Leadership Team at monthly Quality meetings and shared quarterly at the all-manager Quality Meeting.
b. Measurable: Reporting occurs monthly to the Senior Leadership Team and quarterly to all managers.
c. Achievable: This integrates into existing meeting structures.
d. Relevant: Ensures accountability and broad awareness of health equity initiatives and progress.
e. Time-bound: By October 31, 2026 (for establishment of consistent reporting).
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.