KAISER FOUNDATION HOSPITAL – SOUTH SACRAMENTO
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 | 16.8% | 18 to 34 | 6.0% | 2.80 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 17.3% | Private | 7.1% | 2.40 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 13.9% | 18 to 34 | 6.0% | 2.30 |
|
4.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Asian | 47.2% | Multiracial and/or Multiethnic (two or more races) | 78.8% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 11.8% | Private | 7.1% | 1.60 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 8.8% | 18 to 34 | 6.0% | 1.50 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 16.9% | Asian | 11.8% | 1.40 |
|
8.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Asian | 122.2% | White | 92.0% | 1.30 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Black or African American | 62.2% | Multiracial and/or Multiethnic (two or more races) | 78.8% | 1.30 |
|
10.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Female | 101.9% | Male | 81.7% | 1.20 |
2. Equity Plan
Using the health equity report, we will identify the impact of the population. We will reduce HCAI all-cause unplanned 30-day hospital readmissions by 10% within 2 years. We offer our patients culturally tailored patient education, we use interpreters as needed, and we will continue to expand our community partnership and continue workforce training. The top 10 disparities identified in the data highlighted opportunities with All-Cause Readmission Rates, California Maternal Quality Care Collaborative (CMQCC) Exclusive Breast Milk Feeding, and Agency for Healthcare Research and Quality (AHRQ) Measures of Death Rate among Surgical Inpatients and Pneumonia Mortality Rate.
To support improvement in all-cause hospital Readmission and surgical outcomes, Kaiser Foundation Hospital South Sacramento is working to obtain Geriatric Surgical Verification through the American College of Surgeons in November 2026. Achieving Geriatric Surgical Verification reflects a hospital's commitment to improving geriatric surgical care through the implementation of 32 standards to patients 75 years of age or older who are having inpatient surgery. This work also aligns with the Institute for Healthcare Improvement (IHI) Age-Friendly Health Systems (AFHS) recognition and includes focused attention to the unique needs and vulnerability of the older surgical patient. This focused attention guides preoperative and postoperative care pathways that decrease the incidence of negative outcomes, such as readmission and death rate among surgical inpatients, which was identified in our data. The measurable objectives include reducing the 30-day readmission rate for patients aged 65 and older by 10% within 24 months.
To support improvement in Exclusive Breast Milk Feeding, our staff actively offer education regarding breastfeeding and identify any barriers to breastfeeding while encouraging culturally sensitive breastfeeding support. Review of our data identified Asian and Black or African American populations as an opportunity for higher rates. Kaiser Foundation Hospital South Sacramento launched a donor milk program in 2024, which has contributed to an overall improvement in our Exclusive Breast Milk Feeding rate. Additional initiatives include culturally responsive lactation support, community partnerships, interpreter and translation services, data-driven monitoring, and patient-centered education. Our staff continues to promote an antenatal hand expression kit, which provides supplies to support breastfeeding activities in our patients. The goal is to achieve a 5% increase in exclusive breast milk feeding rates for all populations by the end of 2026.
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 the end of 2025 and then IHI AFHS Level 2 Recognition status by the 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.