POMONA VALLEY HOSPITAL 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) | 50 to 64 | 16.9% | 18 to 34 | 5.0% | 3.40 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.7% | 18 to 34 | 5.0% | 3.30 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 17.6% | Private | 5.8% | 3.00 |
|
4.
AHRQ PSI surgical death rate
|
Race and/or Ethnicity | White | 289.5% | Hispanic or Latino | 135.8% | 2.10 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 9.9% | 18 to 34 | 5.0% | 2.00 |
|
6.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 15.8% | Female | 8.5% | 1.90 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.2% | Asian | 9.3% | 1.80 |
|
8.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 10.6% | Private | 5.8% | 1.80 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 17.0% | Female | 9.6% | 1.80 |
|
10.
CMQCC NTSV cesarean rate
|
Age (for maternal measures only) | 30 to 39 | 0.3% | 18 to 29 | 0.2% | 1.70 |
2. Equity Plan
Pomona Valley Hospital is committed to improving care and reducing care inequity within our community. Our leadership team has dedicated resources to assure we meet this commitment. Our multidisciplinary Health, Equity, Diversity and Inclusion (HEDI) committee is the cornerstone of our efforts to address care disparities specifically those addressed in the Hospital Equity Measure Report with the development of action plans, results reporting, timelines and ongoing monitoring. These action plans emphasize care coordination, patient education, and social support and community partnerships.
Majority of the top disparities identified at PVHMC are related to readmissions. Patients aged 50 and greater readmit at a higher rate compared to the reference groups. Black or African American patients have a higher readmission rate than the Asian reference group. Males and males with a behavioral health diagnosis noted to readmit at a higher rate. Additionally, patients with Medicare and Medicaid insurance have a higher readmission rate than the private insurance reference group.
PVHMC has an already established Readmission Performance Improvement Committee who has integrated and emphasized focus on the identified disparities. Data-driven approach is utilized for review, analysis and identification of trends and opportunities of improvement for thorough action planning.
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
https://www.pvhmc.org/patients-visitors/patient-information/
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.