SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF.
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.
Pediatric survey recommend hospital
|
Race/Ethnicity | Hispanic or Latino | 93.0% | Multiracial and/or Multiethnic (two or more races) | 97.6% | 1.10 |
|
2.
Pediatric survey recommend hospital
|
Race/Ethnicity | Black or African American | 94.3% | Multiracial and/or Multiethnic (two or more races) | 97.6% | 1.10 |
|
3.
Pediatric survey recommend hospital
|
Race/Ethnicity | Asian | 94.9% | Multiracial and/or Multiethnic (two or more races) | 97.6% | 1.00 |
2. Equity Plan
Shriners Children's Northern California is committed to providing high quality care to kids with burns, spinal cord injuries and complex orthopedic diagnoses. The current readmission data does not reflect stratification by diagnosis groups that may highlight sub-populations, such as critical burn patients, where readmission rates are equal or better than benchmarks within the pediatric sub-specialty. The 2024 inpatient patient experience scores were very high, ranking in the 97th percentile among similiar national institutions (pediatric hospitals).
The current data has limitations that prevent a full understanding of potential disparities. The most notable gap is the low survey response rate (9.7%) and incomplete collection of Social Drivers of Health (SDOH) data. The facility’s plan focuses on improving data completeness, enhancing patient participation, and building the infrastructure needed to identify and address disparities in a meaningful and sustainable way. A new Electronic Medical Record was implemented in 2025, delivering enhanced capacities for collecting equity and SDOH data
Population Impact: Age is the most prevalent stratification that shows disparities in readmissions. Due to the focused scope of specialties provided at SC Northern California, some higher risk diagnoses may be impacting this data. For patient experience scores, several populations have lower survey completion rates (American Indian/Alaska Native, Black/African American, Asian, and Hispanic/Latino) which may be limiting full assessment of differences in those populations. SDOH data are collected for only a small proportion of adult patients (6 of 157).
Measurable Objectives:
To improve data quality, the hospital will update registration workflows to capture race/ethnicity, preferred language, disability status, sexual orientation/gender identity, and SDOH fields; train staff on the purpose of SDOH collection; and monitor data completeness dashboards. The target is to increase SDOH completion for adult patients from less than 10% to at least 30% within 12 months.
To increase patient experience survey response rates, the facility will expand survey distribution through QR codes, discharge prompts, and verbal reminders; provide culturally responsive education; and implement targeted outreach to low-response populations. T
Targets include increasing the overall survey response rate from 9.7% to at least 12% within one year and improving response rates for AI/AN, Hispanic, Black, and Asian families by at least 3 percentage points each.
Specific Timeframe:
Within 0–3 months, the hospital will update collection workflows, train intake teams, and monitor demographic data capture.
Within 3–6 months, the facility will begin monthly tracking of survey responses; develop follow-up strategies in low-response groups; and initiate SDOH completeness reporting.
At 6–12 months, the facility will achieve at least 30% SDOH completeness, evaluate stratified results quarterly, identify emerging disparities, and share preliminary findings with leadership.
By 12–18 months, the facility will implement at least one disparity-focused intervention, assess its impact, and prepare findings for the next annual equity submission.
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 |
No |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
No |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
No |
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 |
No |
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities |
No |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity |
No |
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 |
No |
4. Web Address for Equity Report
https://www.shrinerschildrens.org/en/locations/northern-cali
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.