KAISER FOUNDATION HOSPITAL – WALNUT CREEK
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 | 15.8% | 18 to 34 | 5.3% | 3.00 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.3% | Private | 6.9% | 2.40 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 12.3% | 18 to 34 | 5.3% | 2.30 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 15.1% | Hispanic or Latino | 9.4% | 1.60 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 12.8% | Hispanic or Latino | 9.4% | 1.40 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 9.1% | Private | 6.9% | 1.30 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 7.0% | 18 to 34 | 5.3% | 1.30 |
|
8.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Asian | 72.8% | Multiracial and/or Multiethnic (two or more races) | 91.1% | 1.30 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 77.3% | Multiracial and/or Multiethnic (two or more races) | 91.1% | 1.20 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 10.3% | Hispanic or Latino | 9.4% | 1.10 |
2. Equity Plan
Readmission: Advance equity-focused healthcare by systematically screening for social risk factors to reduce all-cause unplanned 30-day hospital readmissions by 10% among underserved populations within one year, and across all groups within two years. Key strategies include providing culturally relevant education, using interpreters, strengthening community partnerships for post-discharge support, data stratification to identify disparities, structured referral pathways for high-risk patients, staff training to address care barriers, and ongoing evaluation of community partnership impacts on patient outcomes and readmission rates.
Exclusive Breast Feeding: We currently ensure 100% of our patients are offered education regarding breastfeeding, identifying, and removing any barriers to breast feeding while encouraging culturally sensitive breastfeeding support. This includes our Hispanic/Latino and Asian patients. The ultimate goal is to improve breast feeding rates for all populations while respecting their cultural beliefs and practices. This goal will be achieved by providing culturally tailored in-hospital breastfeeding support, providing bilingual lactation education, and educating staff on common cultural beliefs and barriers affecting breastfeeding for these populations while encouraging culturally sensitive breastfeeding support. Progress will be tracked through participation rates and annual data review, with a focus on closing disparity gaps identified in the health equity report.
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.