KAISER FOUNDATION HOSPITAL – SAN FRANCISCO
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 | 12.9% | 35 to 49 | 6.0% | 2.20 |
|
2.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 20.8% | Hispanic or Latino | 9.7% | 2.10 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 13.3% | Private | 7.3% | 1.80 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 10.8% | 35 to 49 | 6.0% | 1.80 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 10.5% | Private | 7.3% | 1.40 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 13.6% | Hispanic or Latino | 9.7% | 1.40 |
|
7.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Asian | 64.0% | White | 86.3% | 1.30 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 18 to 34 | 7.4% | 35 to 49 | 6.0% | 1.20 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 72.1% | White | 86.3% | 1.20 |
|
10.
CMQCC breast milk feeding
|
Age (for maternal measures only) | 18 to 29 | 65.0% | 30 to 39 | 75.2% | 1.20 |
2. Equity Plan
The report highlights significant disparities in healthcare outcomes, particularly in 30-day readmission rates and exclusive breast milk feeding rates. The highest 30-day readmission rates are observed among patients aged 65 and older (12.8%), multiracial/multiethnic individuals (20.8%), Medicare recipients (13.2%), Medicaid recipients (10.2%), and Black/African American patients (13.1%). Additionally, exclusive breast milk feeding rates are notably lower among Asian, Hispanic/Latino, and younger maternal age groups. To address these disparities, key initiatives include implementing the 4Ms framework (Mentation, Mobility, Medication, What Matters) in discharge planning and post-discharge follow-up for older adults. The strategic integration of the 4Ms into readmission risk assessment involves aligning care with patient goals, optimizing and deprescribing medications, screening and acting on cognitive risks, and preserving function and preventing falls. The measurable objectives include reducing the 30-day readmission rate for patients aged 65 and older by 10% within 12 months and reducing the readmission rate for multiracial/multiethnic patients by 10% within the same timeframe. The overall timeframe for these initiatives is from Q4 2025 to Q4 2026.
For exclusive breast milk feeding rates, the target populations are Asian, Hispanic/Latino, and younger maternal age groups (18-29). Initiatives include culturally responsive lactation support, community partnerships, interpreter and translation services, data-driven monitoring, and patient-centered education. The goal is to achieve a 5% increase in exclusive breast milk feeding rates among these groups within 12 months, increase the percentage of mothers receiving lactation support prior to discharge, and improve patient satisfaction scores related to maternity and newborn care education.
The Regional Age Friendly Hospital System (AFHS) Core Team will be leading and supporting all 21 KP NCAL facilities to achieve IHI AFHS Level 1 Recognition status by end of 2025 and then HI AFHS Level 2 Recognition status by end of 2026. The team will also ensure that all facilities have protocols in place to affirmatively attest to receive full credit for all 5 Domains of the CMA AFHS Measure by May 2025. This will position our hospitals to consistently and reliably provide high quality care to all hospitalized elderly patients.
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.