SHARP CHULA VISTA 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) | 65 and older | 15.8% | 18 to 34 | 6.4% | 2.50 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 14.8% | 18 to 34 | 6.4% | 2.30 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.2% | Private | 7.5% | 2.20 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 11.6% | 18 to 34 | 6.4% | 1.80 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 21.8% | Asian | 12.6% | 1.70 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 12.7% | Private | 7.5% | 1.70 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 18.5% | Asian | 12.6% | 1.50 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.8% | Asian | 12.6% | 1.20 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 13.3% | Asian | 12.6% | 1.10 |
|
10.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Female | 38.2% | Male | 37.1% | 1.00 |
2. Equity Plan
Sharp Chula Vista Medical Center is actively working to advance health equity through strategic
initiatives. The hospital collaborates with Sharp HealthCare on both entity-specific and system-wide
efforts. These initiatives focus on identifying priority populations experiencing health disparities,
setting health equity goals, developing action plans to achieve these goals, and engaging key
stakeholders across the organization. This comprehensive approach aims to address and reduce
health disparities, especially as they relate to all-cause 30-day readmissions and mortality rates.
According to the Hospital Equity Report, nine of SCV's top ten disparities are related to elevated
readmission rates, with the tenth highlighting increased death rates among female patients with
pneumonia. SCV's top disparities show higher readmission rates among patients from certain
racial and ethnic backgrounds, those covered by Medicaid and Medicare, and variable impact by
age. SCV has targeted interventions to address both readmissions and mortality.
SCV has a Readmissions and Mortality Taskforce composed of service line leaders who review all
readmissions to identify opportunities for improvement. The hospital has implemented a robust
discharge process that includes scheduling follow-up appointments within seven days of discharge,
ensuring patients leave with necessary medications through the Discharge Prescription Services
program, and educating patients on medication adherence.
All patients are screened for social determinants of health (SDOH), and those with identified needs
are connected to community resources such as 211 San Diego and the Community Information
Exchange (CIE). SCV is also partnered with the Community Research Foundation's Healthy
Connect Enhanced Care Management (ECM) program to support high-risk patients with
wraparound services.
SCV's interdisciplinary approach includes collaboration across hospital disciplines and services.
For example, one unit identified a gap in post-operative education due to language barriers and
cultural beliefs. In response, the team developed multilingual educational materials tailored to patient
needs, resulting in a reduction in readmissions over the past several months.
Sharp HealthCare establishes annual goals to reduce both 30-day and 7-day readmissions, and
SCV contributes through its entity-specific taskforce focused on high-risk populations and diseasespecific strategies. SCV is planning to implement additional strategies to improve post-discharge
care, including increasing discharge phone calls, expanding prescription services to all high-risk
patients, and enhancing referrals to outpatient providers with secured follow-up appointments.
SCV remains committed to a Diversity, Equity, Inclusion, & Belonging (DEIB) Framework that
integrates training to increase staff awareness of varied patient needs. These principles are
embedded into internal policies, systems, and behaviors across the organization. Sharp HealthCare
has also developed a system-wide equity dashboard to visualize performance across key equity
measures, guiding SCV's performance improvement work.
This ongoing process of assessing needs, identifying inequalities, and closing gaps supports
SCV's mission to deliver high-quality, patient-centered care to all members of its diverse
community.
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
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.