PROVIDENCE QUEEN OF THE VALLEY 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 NOBH	Expected Payor	Other	11.9%	Private	2.8%	3.40
2. HCAI 30-Day readmission NOBH	Expected Payor	Medicare	10.6%	Private	2.8%	3.30
3. HCAI 30-Day readmission	Expected Payor	Other	11.9%	Private	3.8%	3.10
4. HCAI 30-Day readmission	Expected Payor	Medicare	10.6%	Private	3.8%	2.80
5. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	13.0%	18 to 34	4.7%	2.80
6. HCAI 30-Day readmission SUD	Race and/or Ethnicity	Hispanic or Latino	21.9%	White	9.9%	2.20
7. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	10.2%	18 to 34	4.7%	2.20
8. CMQCC NTSV cesarean rate	Expected Payor	Private	0.2%	Medicaid	0.1%	2.00
9. CMQCC NTSV cesarean rate	Expected Payor	Other	0.0%	Medicaid	0.1%	2.00
10. HCAI 30-Day readmission MHD	Race and/or Ethnicity	Hispanic or Latino	15.6%	White	10.3%	1.50

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2. Equity Plan

Healthcare disparities in unplanned 30-day readmission rates remain a pressing issue for multiple patient groups. Addressing these disparities is essential for improving outcomes, reducing costs and promoting equity in care. This report outlines targeted best practice actions for 3 specific groups. (1) patients without behavior health disorders on Medicare and other insurance (2) patients on Medicaid and other insurances aged 50 years and older and (3) patients with a behavioral health diagnosis who are Hispanic or Latino. Group 1: Goal is to reduce 30-day readmission rates by 10% within 18 months. This will be achieved by the following- - Increase post discharge follow up rates to 90% within 12 months - Improve medication reconciliation accuracy to 95% within 12 months - Improve compliance with discharge education to 100% within 12 months Actions- - For all high risk for readmission patients our care transition teams will facilitate follow-up appointments and home visits if appropriate - Implement pharmacist-led discharge reconciliation to ensure accurate medication lists and optimize therapeutic regimens prior to patient discharge. Conduct a follow-up call within 48 hours of discharge to address any medication related questions or concerns and verify adherence - Standardized discharge protocols ensuring clear communication and individualized plans of care. Implementation of a comprehensive discharge checklist to ensure patients receive thorough education and preparation before leaving the hospital. Group 2: Goal is to reduce 30-day readmission rates by 10% within 18 months. This will be achieved by the following- - Increase post discharge follow up rates to 90% within 12 months - Improve medication reconciliation accuracy to 95% within 12 months - Improve compliance with discharge education to 100% within 12 months Actions- - For all high risk for readmission patients our care transition teams will facilitate follow-up appointments and home visits if appropriate - Implement pharmacist-led discharge reconciliation to ensure accurate medication lists and optimize therapeutic regimens prior to patient discharge. Conduct a follow-up call within 48 hours of discharge to address any medication related questions or concerns and verify adherence - Standardized discharge protocols ensuring clear communication and individualized plans of care. Implementation of a comprehensive discharge checklist to ensure patients receive thorough education and preparation before leaving the hospital. Group 3- Goal is to reduce 30-day readmission rates by 10% within 18 months. This will be achieved by the following- - Increase post discharge follow up rates to 90% within 12 months - Improve medication reconciliation accuracy to 95% within 12 months - Improve compliance with discharge education to 100% within 12 months Actions- - For all high risk for readmission patients our care transition teams will facilitate follow-up appointments and home visits if appropriate - Implement pharmacist-led discharge reconciliation to ensure accurate medication lists and optimize therapeutic regimes prior to patient discharge. Conduct a follow-up call with interpreter within 48 hours of discharge to address any medication related questions or concerns and verify adherence - Standardized discharge protocols ensuring clear communication and individualized plans of care. Implementation of a comprehensive discharge checklist to ensure patients receive thorough education and preparation before leaving the hospital. - Multilingual Discharge Materials: Provide discharge materials in multiple languages to accommodate divers population and improve comprehension - Strengthen coordination with primary care and behavioral health providers for post follow up care - Integrate telehealth services for behavioral health support during hospitalization Healthcare disparities in Nulliparous Term Singleton Vertex Cesarean (NTSV) Birth Rates remain a pressing issue for patients who have Private or other insurance. Goal is to reduce NTSV rates by 5% within 18 months. This will be achieved by the following- - Physiological birth committee meets monthly that promotes nursing techniques to promote optimal rotation and descent of fetal heads which promotes vaginal births - Mandatory skills practicum for all Labor and Delivery nurses following evidence-based practices for promoting physiological vaginal births - Ensure CMQCC NTSV checklist is utilized for each NTSV C-section - Case review for all NTSV fallouts at Dept Quality Meeting and sent to Peer Review if needed. - Enhanced education for patients at high risk for NTSV- patients who conceived via IVF, patients older than 35 years

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

PROVIDENCE QUEEN OF THE VALLEY MEDICAL CENTER