KAISER FOUNDATION HOSPITAL – ONTARIO

KAISER FOUNDATION HOSPITAL – ONTARIO

2295 S. VINEYARD AVENUE, ONTARIO, CA 91761
HCAI ID
106364265
Reporting Organization
KAISER FOUNDATION HOSPITAL- ONTARIO
Report Period
01/01/2024 – 12/31/2024
Hospital / Hospital System
Hospital
Report Type
General Acute Care Hospital
License No
240000159
Licensee
KAISER FOUNDATION HOSPITALS
County
San Bernardino

System Report

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) 65 and older 16.3% 18 to 34 4.3% 3.80
2. HCAI 30-Day readmission
Age (excluding maternal measures) 50 to 64 12.9% 18 to 34 4.3% 3.00
3. HCAI 30-Day readmission
Expected Payor Medicare 16.8% Private 7.1% 2.30
4. HCAI 30-Day readmission
Age (excluding maternal measures) 35 to 49 9.1% 18 to 34 4.3% 2.10
5. HCAI 30-Day readmission
Race and/or Ethnicity Black or African American 16.4% Hispanic or Latino 9.9% 1.70
6. HCAI 30-Day readmission NOBH
Sex Assigned at Birth Male 13.8% Female 8.5% 1.60
7. CMQCC NTSV cesarean rate
Age (for maternal measures only) 30 to 39 0.3% 18 to 29 0.2% 1.50
8. HCAI 30-Day readmission
Sex Assigned at Birth Male 14.5% Female 9.6% 1.50
9. AHRQ pneumonia mortality rate
Race and/or Ethnicity White 81.8% Hispanic or Latino 53.3% 1.50
10. HCAI 30-Day readmission
Sex Assigned at Birth Male 14.5% Female 9.6% 1.50

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2. Equity Plan

Kaiser Permanente Southern California has identified five key health disparities and developed a focused action plan to address them. The plan targets performance across priority areas including person-centered care, patient safety, social determinants of health (SDOH), effective treatment, care coordination, and access to care. Our goal is to ensure that all members regardless of race, ethnicity, gender, income, ZIP code, or other protected characteristics receive high-quality, equitable care. The plan outlines measurable objectives with defined timelines and tracks progress using equity performance metrics, member feedback, and claims data. Recognizing that advancing equity requires collaboration, we partner with community organizations, providers, and members to co-design interventions reflecting the needs of the communities we serve.

Our strategy builds on evidence-based interventions such as early outreach, transitional care, chronic disease management, social support, and continuous data monitoring. One core initiative is a standardized care transition pathway that begins during hospitalization with structured patient education and readiness assessments. Language-concordant discharge planning ensures understanding of care instructions, while post-discharge steps include a follow-up call within three days, a provider visit within seven days, medication reconciliation, and enrollment in chronic condition programs. High-risk patients are identified using EHR-based risk stratification tools, and embedded decision prompts guide care teams to promote consistency and timely intervention.

To improve maternal outcomes, we are reducing the Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate in alignment with the California Maternal Quality Care Collaborative (CMQCC). Our approach includes labor support training for over 80% of nurses, revised induction protocols, standardized labor management, and enhanced provider education. A multidisciplinary team of obstetricians, midwives, nurses, and anesthesiologists promotes informed decision-making and patient support. Prenatal education programs inform expectant mothers about labor expectations, cesarean risks, and birth options. Data monitoring and provider-level feedback track progress, while expanded use of hydrotherapy, ambulation, and other non-medical pain management techniques reduce intervention reliance. We also promote safe Vaginal Birth After Cesarean (VBAC) through counseling and protocol development to lower cesarean rates without compromising outcomes.

We are also reducing the incidence and improving outcomes of serious but treatable complications such as sepsis, acute kidney injury, and respiratory failure. 24/7 Rapid Response Teams (RRTs) are deployed across inpatient units to standardize early intervention. High-risk groups - elderly and post-surgical patients are prioritized in acute and ICU settings. Staff receive regular training on sepsis bundles and protocols, supported by mock surveys. Checklists and workflows are updated to ensure early detection and consistent monitoring during care transitions. Metrics including response times and complication rates are continuously tracked for quality improvement.

To reduce pneumonia mortality, we have implemented a population-level strategy focused on prevention, early diagnosis, and effective treatment. This begins with assessing disease burden, high-risk groups, and service gaps in vaccination, diagnostics, and oxygen availability. Preventive measures include scaling up pneumococcal, Hib, and influenza vaccination coverage; promoting exclusive breastfeeding for six months; improving nutrition; reducing air pollution; and supporting hygiene and smoking cessation. Community health workers identify pneumonia early using standardized tools and refer patients promptly.

At the facility level, pneumonia management protocols are embedded into clinical workflows to ensure appropriate antibiotic and oxygen use. Investments in oxygen systems and supply chains strengthen treatment readiness. Broader system capacity is built through workforce training, infrastructure upgrades, and data monitoring. Mortality reviews and continuous quality improvement initiatives promote adherence to clinical standards. Outreach programs in underserved communities ensure equitable access to prevention and care of pneumonia.

Our measurable objectives include achieving over 90% vaccination coverage for target populations, reducing pneumonia mortality by at least 50% within five years, and lowering hospital case fatality rates below 5%. Progress will be monitored through real-time dashboards, disaggregated data, and performance reviews. Through these focused, collaborative, and data-driven efforts, we are making measurable strides toward eliminating health disparities and ensuring equitable care for all members.

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

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4. Web Address for Equity Report

https://tinyurl.com/4as5es34

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

Hospital Equity Measures Report Download

Click on the link below to download all equity measures reports.

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