HEALDSBURG 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.
No disparity data for this period.
2. Equity Plan
HCAHPS survey: Q. 17 Received information and education (H-COMP-6-Y-P) The disparity groups for the patient population to improve the HCAHPS survey question on "During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital" include: - Sex assigned at birth: Male - Race: White Measurable Goal: Improve the HCAHPS Top Box score for survey question "During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital" by 1% for white and male patient populations. Target Date: December 31, 2026. Actions: - Practice "Teach Back" method to educate and validate patient/caregiver understanding of symptoms or health problems to look out for after they leave the hospital. - Provide each patient/family member with the After Visit Summary (AVS) at discharge. The AVS/discharge summary document explains why they were hospitalized, medications to continue/stop, signs/symptoms to watch for, when to seek help, how to care for self, follow-up appointments. - Provide verbal and written information and education in patients' preferred language. - Refer patients with high risk for readmission and complex treatment regimens to Providence Care Network for outpatient treatment plan support. - Round on patients asking scripted questions regarding the patient's perception of how care is being delivered and to allow the opportunity to provide information/education to the patient/family. (Unit Leaders) - Ask patients "What Matters Most" and post on patient board (Patient's RNs). Responses posted for the care team to see and incorporate into the care plan. Data Measure: HCAHPS Top Box score for survey question "During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital". HCAHPS survey: Q. 19 Would Recommend Hospital (H-RECMND-DY) The disparity groups for the patient population to improve the HCAHPS survey question on "Would you recommend this hospital to your friends and family?" include: - Sex assigned at birth: Female - Race: Hispanic/Latino Measurable Goal: Improve the HCAHPS Top Box score for survey question "Would you recommend this hospital to your friends and family?" by 1%. Target Date: December 31, 2026. Actions: (1) Enhance PERSON-CENTERED CARE o Ask patients "What Matters Most?" and post on patient board (Patient's RNs). Responses posted for care team to see and incorporate into the care plan. o Personalize and update information for the patient/family regarding who their care team is, activity level, diet status, patient specific needs, and a section for patients/families to write questions. o Screen all patients for preferred language, ensure qualified interpreters are available for non-English speaking patients. Provide educational materials in patient's preferred language to support understanding and engagement, enabling every patient to fully comprehend their care plan and actively participate in decision-making. o Utilize interpreter services for patients with preferred language other than English. (2) Incorporate Social Determinants of Health (SDoH) positive screening into care plan. o FindHelp is used to generate a comprehensive list of local resources for housing, utilities, food, transportation to support health and well-being to support excellent health outcomes. Data Measure: HCAHPS Top Box score for survey question Would you recommend this hospital to your friends and family?"
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
https://www.providence.org/locations/norcal/healdsburg-distr
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.