MILLS-PENINSULA MEDICAL CENTER

1501 TROUSDALE DRIVE, BURLINGAME, CA 94010
HCAI ID
106410852
Reporting Organization
Sutter Health
Report Period
01/01/2024 – 12/31/2024
Hospital / Hospital System
Hospital
Report Type
General Acute Care Hospital
License No
220000037
Licensee
SUTTER BAY HOSPITALS
County
San Mateo

System Report

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
Expected Payor Medicare 10.1% Private 3.9% 2.60
2. HCAI 30-Day readmission NOBH
Sex Assigned at Birth Male 8.0% Female 3.5% 2.30
3. CMQCC breast milk feeding
Race and/or Ethnicity Asian 45.1% White 80.5% 1.80
4. HCAI 30-Day readmission
Sex Assigned at Birth Male 8.4% Female 5.1% 1.60
5. CMQCC breast milk feeding
Expected Payor Other 42.9% Medicaid 61.5% 1.40
6. HCAI 30-Day readmission MHD
Age (excluding maternal measures) 65 and older 11.7% 50 to 64 8.5% 1.40
7. CMQCC breast milk feeding
Race and/or Ethnicity Hispanic or Latino 63.3% White 80.5% 1.30
8. HCAI 30-Day readmission
Age (excluding maternal measures) 65 and older 8.9% 50 to 64 7.2% 1.20
9. HCAI 30-Day readmission
Race and/or Ethnicity White 6.8% Asian 5.6% 1.20
10. HCAI 30-Day readmission NOBH
Age (excluding maternal measures) 65 and older 7.7% 50 to 64 6.5% 1.20

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2. Equity Plan

Mills-Peninsula Medical Center's health equity plan is greater than 5,000 characters. It has been submitted to HCAi and published to the hospital's website as a supplemental PDF file.

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

No

Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information

No

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

No

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

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4. Web Address for Equity Report

https://www.sutterhealth.org/mpmc-equity-report

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

Hospital Equity Measures Report Download

Click on the link below to download all equity measures reports.

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