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.
HCAI 30-Day readmission NOBH
|
Expected Payor | Medicare | 8.9% | Private | 3.2% | 2.80 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 9.7% | Private | 4.4% | 2.20 |
|
3.
CMQCC NTSV cesarean rate
|
Age (for maternal measures only) | 30 to 39 | 0.2% | 18 to 29 | 0.1% | 2.00 |
|
4.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Asian | 48.8% | Multiracial and/or Multiethnic (two or more races) | 96.0% | 2.00 |
|
5.
HCAI 30-Day readmission NOBH
|
Age (excluding maternal measures) | 65 and older | 8.6% | 50 to 64 | 5.9% | 1.50 |
|
6.
HCAI 30-Day readmission CO
|
Age (excluding maternal measures) | 65 and older | 14.3% | 50 to 64 | 10.5% | 1.40 |
|
7.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 8.2% | Female | 6.5% | 1.30 |
|
8.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Asian | 48.8% | Multiracial and/or Multiethnic (two or more races) | 96.0% | 1.30 |
|
9.
HCAHPS survey-recommend hospital
|
Age (excluding maternal measures) | 50 to 64 | 96.3% | 18 to 34 | 100.0% | 1.20 |
|
10.
CMQCC breast milk feeding
|
Race and/or Ethnicity | American Indian or Alaska Native | 76.3% | Multiracial and/or Multiethnic (two or more races) | 96.0% | 1.20 |
2. Equity Plan
Healthcare disparities in unplanned 30-day readmission rates (RR) remain a significant concern for various patient populations. These disparities present ongoing challenges that impact not only patient outcomes but also healthcare costs and the overall equity of care provided. Effectively addressing such disparities is a critical step toward ensuring that all patients receive high-quality care, experience better health outcomes, and benefit from a more equitable healthcare system. Healthcare disparities in unplanned 30-day RR remain a pressing issue for multiple patient groups. Addressing these disparities is essential for improving outcomes, reducing costs and promoting equity in care. Group 1, 2, 5, 6, 7, 8,10: Goal is to reduce 30-day RR 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 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. - Prioritize follow up care for patients with a high risk of readmission based on LACE screening tool. Healthcare disparities in Nulliparous Term Singleton Vertex Cesarean (NTSV) Birth Rates remain a pressing issue for 30-39-year-old females as compared to 18-29-year-old females. Group 3: Goal is to reduce NTSV rates by 5% within 18 months. This will be achieved by the following- - Screen NTSV cesarean births looking for any disparities to 100% within 12 months - Disseminate 100% of results of all screenings with hospital leadership and perinatal medical staff to highlight areas of improvement opportunities with multidisciplinary teams within 6 months. - Physicians are provided with their individual Cesarean Metric reports available through CMQCC. Actions- - 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 by Quality Department and L&D clinical coordinator. Opportunities are presented to providers and nursing if needed. Group 4: Goal is to improve breast feeding rates for Asian population as compared to multiracial population by 10% within 18 months. This will be achieved by the following- - Provide lactation committee with data stratified by race and/or ethnicity to 100% of the meetings within 6 months - Improve compliance with breastfeeding education in primary language to 100% within 12 months Actions- - Collaborate with lead of lactation committee to ensure data is presented and understood. - Standardized discharge protocols ensuring clear communication and individualized plans of care. Implementation of a comprehensive education on the benefits of breastfeeding Group 9- Goal is to reduce 30-day RR 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. - Prioritize follow up care for patients with a high risk of readmission based on LACE screening tool. - Strengthen coordination with primary care and behavioral health providers for post follow up care - Integrate telehealth services for behavioral health support during hospitalization
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.