PROVIDENCE ST. JOSEPH 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.
CMQCC breast milk feeding
|
Expected Payor | Self-Pay | 15.0% | Private | 76.2% | 5.10 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 9.3% | 18 to 34 | 3.1% | 3.00 |
|
3.
HCAI 30-Day readmission NOBH
|
Age (excluding maternal measures) | 65 and older | 8.4% | 18 to 34 | 3.0% | 2.80 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 7.5% | 18 to 34 | 3.1% | 2.40 |
|
5.
HCAI 30-Day readmission NOBH
|
Age (excluding maternal measures) | 50 to 64 | 7.2% | 18 to 34 | 3.0% | 2.40 |
|
6.
HCAI 30-Day readmission MHD
|
Expected Payor | Medicare | 11.8% | Private | 5.1% | 2.30 |
|
7.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Asian | 38.3% | White | 82.0% | 2.10 |
|
8.
HCAI 30-Day readmission MHD
|
Expected Payor | Other | 10.8% | Private | 5.1% | 2.10 |
|
9.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 6.3% | 18 to 34 | 3.1% | 2.00 |
|
10.
CMQCC NTSV cesarean rate
|
Age (for maternal measures only) | 40 and older | 0.4% | 18 to 29 | 0.2% | 2.00 |
2. Equity Plan
- CMQCC Exclusive Breast Milk Feeding (PC-05) The disparity group for the patient population to improve Exclusive Breast Milk Feeding include: - Self-Pay [best performing: Private] - Asian [best performing: White] Goal: Improve Exclusive Breast Milk Feeding 5% by the end of 2026. This will be achieved by the following actions: - Teach Back - Teach back is utilized to educate and validate patient understanding. - Provide education and information materials to the patient surrounding breast milk feeding prior to delivery and after delivery. - Implementation of a mobile app that patients can utilize to reference education materials. - HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate (HCAI-SS-HWR) - All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (No Behavioral Health Disorders) - All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (MHD) The disparity group for the patient populations to improve all-cause unplanned 30-day hospital readmission rate include: - 65 and Older [best performing: 18 to 34] - 50 to 64 [best performing: 18 to 34] - Medicare [best performing: Private] - Other [best performing: Private] - 35 to 49 [best performing: 18 to 34] Goal: Report an O:E of less than 1.0 for 30-day readmission rates for the above disparity group by end of 2026. This will be achieved by the following actions: - Utilize evidence-based readmission risk assessment tool to flag high risk patients - Utilization of a Discharge Checklist for identified patient cohorts to prevent readmission. - Utilize discharge follow-up phone calls for high lace score Medicare patients. - Assess all patients for SDOH needs and provide any resources available to help the patient upon discharge. - Engage Social Work to provide local community resources from FindHelp - Partner with Community Health Investment to support connection to community resources - Work with Case Management to assist with making Follow-Up Appointments. - Implement a pathway for care planning conversations and referrals around palliative care. Currently have this for Heart Failure, but piloting triggers for COPD patients. - For behavioral health patients: o Include behavioral health assessment early in the admission o Engage mental health resources into discharge planning, including substance use disorders - Implement a process, which include behavioral health caregivers, that allow the opportunity for patients who cannot be admitted onto the behavioral health unit to be seen by a behavioral health nurse prior to discharge. - CMQCC Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate (PC-02) The disparity group for the patient population to improve Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate (PC-02) include: - 40 and Older [best performing: 18 to 29] Goal: Improve Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate (PC-02) 5% by the end of 2026. This will be achieved by the following actions: - Weekly updates and reviews of any fallouts by L&D Leadership, CNO, CMO, and Quality. - Develop standard work with Provider Buy-In for induction/augmentation management and expectations. - Review other Hospital practices who are high-performing and compare our current practice to identify opportunities. - Implement a multi-disciplinary NTSV workgroup to review opportunities and action plans.
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.