ST. FRANCIS 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 | 17.9% | 18 to 34 | 5.1% | 3.50 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 16.4% | 18 to 34 | 5.1% | 3.20 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 10.8% | 18 to 34 | 5.1% | 2.10 |
|
4.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 15.5% | Female | 9.0% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 16.9% | Female | 10.2% | 1.70 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 15.5% | Hispanic or Latino | 12.0% | 1.30 |
|
7.
HCAI 30-Day readmission
|
Preferred Language | Spanish Language | 15.7% | English Language | 11.6% | 1.30 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 15.5% | Hispanic or Latino | 12.0% | 1.30 |
|
9.
HCAI 30-Day readmission
|
Expected Payor | Private | 13.5% | Medicare | 12.0% | 1.10 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 13.2% | Hispanic or Latino | 12.0% | 1.10 |
2. Equity Plan
To address the identified disparities in 30-day hospital readmission rates, our Equity Plan focuses on targeted interventions for the most affected populations. Older adults (65+) and middle-aged adults (50–64) show the highest readmission rates, indicating a need for enhanced transitional care and discharge planning. We plan to implement a structured follow-up program that includes post-discharge check-ins, medication reconciliation, and coordination with primary care providers. For racial and ethnic disparities, particularly among White and Black/African American patients, we will conduct a root cause analysis to understand contributing factors such as access to outpatient care and cultural responsiveness. Spanish-speaking patients will benefit from expanded language services, including translated discharge instructions and interpreter support. For males, especially those without behavioral health diagnoses, we will implement better post-discharge coordination strategies. Our measurable objectives include reducing readmission rates by at least 8% for each disparity group within 12 months. The timeline includes planning and stakeholder engagement in Q1–Q2, pilot implementation in Q3, and evaluation and scaling in Q4.
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.