MERCY SOUTHWEST HOSPITAL
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 | 5.2% | 3.10 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 16.2% | 18 to 34 | 5.2% | 3.10 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 11.3% | 18 to 34 | 5.2% | 2.20 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.8% | Private | 7.9% | 2.10 |
|
5.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 15.0% | Female | 8.6% | 1.70 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 16.6% | Hispanic or Latino | 10.5% | 1.60 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 16.5% | Hispanic or Latino | 10.5% | 1.60 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 15.7% | Female | 10.4% | 1.50 |
|
9.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 11.4% | Private | 7.9% | 1.40 |
|
10.
CMQCC NTSV cesarean rate
|
Expected Payor | Private | 0.2% | Medicaid | 0.1% | 1.30 |
2. Equity Plan
Disparity 1-2, and 4 Plan: Age-Related Readmit Disparities (65+, 50-64, and 35-49 Vs.18-34)
Population Impact: Adults 35-65+ experiencing higher unplanned readmissions compared to younger patients (18-34).
Action Plan: Enhanced chronic disease management education during hospitalization for older patients. Increase utilization of transitional care clinics to bridge the gap for high risk/older patients. Follow up phone calls within 48-72 hours after discharge.
Measurable Objectives: Reduce 30-day all-cause readmissions by 15% over the next 2 years.
Disparity 3 and 9 Plan: Expected Payor-Related readmit Disparities (Medicare and Medicaid VS Private Insurance)
Population Impact: Adults over 65, persons with disabilities, and persons of all ages with state/federal funded healthcare.
Action Plan: Enhanced chronic disease management education during hospitalizations for patients with high risk factors and/or complex comorbidities. Increase utilization of transitional care clinics, telemedicine, and home health to bridge the gap and ensure a smoother transition to recovery. Follow up phone calls within 48-72 hours after hospital discharge.
Measureable Objectives: Reduce 30-day all-cause readmissions by 15% over the next 2 years.
Disparity 5 and 8 Plan: Sex Assigned at Birth Related Readmit Disparities
Population Impact: Males
Action Plan: Provide male-centered health education focusing on medication adherence, lifestyle management, and follow-up care. Strengthen discharge planning with clear, simplified instructions and early outpatient follow-up for high-risk male patients.
Measureable Objectives: Reduce 30-day all-cause readmissions by 15% over the next 2 years.
Disparity 6 and 7 Plan: Race and/or Ethnicity Readmit Disparities (Asian and Black or African American VS Hispanic or Latino)
Population Impact: Asian and Black or African American population
Action Plan: Provide discharge instructions and health education in culturally relevant formats and languages. Address barriers such as housing, food security, and access to medications that disproportionately affect African American and Asian men.
Measurable Objectives: Reduce 30-day all-cause readmissions by 15% over the next 2 years.
Disparity 10 Plan: Expected Payer (NTSV) C-Section Birth Rate by Expected Payor (Private Insurance VS Medicaid)
Population Impact: Pregnant people at least 37 weeks gestation who had a Cesarean Section birth during their first pregnancy who also have Private Insurance.
Action Plan: 62% of our Labor and Delivery nurses have completed Spinning Babies education. This education teaches the nurses and expecting pregnant people gentle exercises and body positions that encourage optimal fetal positioning. For babies in a breech position, these techniques may encourage them to turn head-down naturally, thus reducing the need for Cesarean Deliveries.
Measureable Objectives: Reduce the volume of cesarean section births carried out for non-medical related reasons over the next year.
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.