MARSHALL MEDICAL CENTER
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 | 15.2% | 18 to 34 | 3.5% | 4.30 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 13.4% | 18 to 34 | 3.5% | 3.80 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 7.6% | 18 to 34 | 3.5% | 2.20 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 14.6% | Medicaid | 7.2% | 2.00 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Private | 12.8% | Medicaid | 7.2% | 1.80 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 13.2% | Hispanic or Latino | 8.7% | 1.50 |
|
7.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 14.0% | Female | 12.1% | 1.20 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 13.6% | Female | 12.1% | 1.10 |
2. Equity Plan
Marshall continues to advance its commitment to health equity by identifying, prioritizing, and addressing disparities through community partnership and data-driven improvement. Current analysis identified eight measurable disparities within the All-Cause Unplanned 30-Day Readmission Rate. These represent opportunities for improvement and shared learning rather than indicators of harm. Limited representation of BIPOC populations highlights the need for continued outreach and improved demographic data collection. Efforts are focused on building trust and inclusive participation to ensure our data reflects all communities served. Preventing Readmissions is a top organizational priority with significant ongoing interdisciplinary efforts to improve overall and for specific sub populations.
The root cause issues identified in driving readmissions and preventable Emergency Department admissions include complicated hospital discharge instructions and limited care coordination post operatively for outpatient surgeries. For discharge instructions, Marshall has a team of RNs and MDs reviewing standard instructions for high-frequency conditions to ensure the most important information is shared in the simplest manner possible, and shifting our EMR system to prompt use of the forms that meet this criteria. For post operative care coordination, Marshall has implemented improved timeliness of Home Health referrals pre-operatively and coordinated across service lines to align post-operative phone call follow up and education being offered to patients. Across initiatives, Marshall continues to stratify outcomes to identify disparately impacted subpopulations as well as review individual charts to better understand individual patient needs.
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.