MOTION PICTURE AND TELEVISION 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.
No disparity data for this period.
2. Equity Plan
Due to the small population our hospital serves and the resulting suppression of stratified groups, no disparities were identified based on our hospital’s data. Here is the action plan as we move forward.
A. Hospital Consumer Assessment of Service Provided
1. Continue collecting and stratification of the data:
a) Review patient satisfaction data from HCAHPS survey and stratify it by demographic factors like race, ethnicity, language, sexual orientation, gender identity, disability status, and social determinants of health to identify where satisfaction gaps exist.
b) Conduct a needs assessment to understand the root causes of lower satisfaction overall and within specific groups.
2. Implement targeted interventions
a) Enhance communications.
b) Personalize the patient experience by ensuring care plans are individualized to patient needs, cultural backgrounds, and preferences.
c) Involve patients in their care decisions.
d) Ensure facilities are clean, safe, and comfortable, with improved accessibility.
e) Support staff:
1) Provide ongoing education on cultural competency and addressing implicit bias.
2) Foster a patient-centric culture and provide training on how to deliver it.
3. Monitor and adapt
a) Utilize patient feedback: Continuously collect patient feedback through surveys, online reviews, and direct communication to monitor
the impact of interventions.
b) Track outcomes by analyzing satisfaction data and other relevant quality metrics to determine if disparities are decreasing over time.
c) Adapt and adjust the plan based on feedback and performance data to ensure continuous improvement.
B. HCAI All Cause Unplanned 30-Day Readmission stratified by behavioral health disorder (Mental Health disorder)
1. Conduct a review of each unplanned 30-day admission to gain understanding of the root cause(s) of the readmissions.
2. Stratify by type of unplanned 30-day admission and demographics.
3. Identify and implement process improvements with the primary focus on the readmission to an inpatient behavioral health facility.
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 |
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.