STANFORD HEALTH CARE

500 PASTEUR DRIVE, PALO ALTO, CA 94304
HCAI ID
106430035
Reporting Organization
STANFORD HEALTH CARE
Report Period
01/01/2024 – 12/31/2024
Hospital / Hospital System
Hospital
Report Type
General Acute Care Hospital
License No
070000662
Licensee
STANFORD HEALTH CARE
County
Santa Clara

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. AHRQ PSI surgical death rate
Age (excluding maternal measures) 65 and older 244.7% 50 to 64 119.6% 2.00
2. HCAI 30-Day readmission
Race and/or Ethnicity American Indian or Alaska Native 26.7% White 15.7% 1.70
3. AHRQ pneumonia mortality rate
Sex Assigned at Birth Male 66.0% Female 39.9% 1.70
4. HCAI 30-Day readmission
Race and/or Ethnicity Hispanic or Latino 21.6% White 15.7% 1.40
5. HCAI 30-Day readmission
Expected Payor Medicaid 21.9% Private 16.1% 1.40
6. HCAI 30-Day readmission
Race and/or Ethnicity American Indian or Alaska Native 26.7% White 15.7% 1.30
7. HCAI 30-Day readmission
Preferred Language Spanish Language 22.1% English Language 17.0% 1.30
8. HCAI 30-Day readmission
Age (excluding maternal measures) 35 to 49 20.4% 65 and older 15.8% 1.30
9. HCAI 30-Day readmission
Age (excluding maternal measures) 50 to 64 19.2% 65 and older 15.8% 1.20
10. HCAI 30-Day readmission
Race and/or Ethnicity Native Hawaiian or Pacific Islander 18.6% White 15.7% 1.20

View Fullscreen

2. Equity Plan

Stanford Health Care (SHC) is guided by our mission to heal humanity through science and compassion. We are committed to person-centered, equitable care that improves access, quality, safety, patient experience, and clinical outcomes.
SHC reviewed the top 10 disparities identified using the HCAI Hospital Equity Measures methodology and developed a comprehensive plan to address variation in outcomes and patient experience. As indicated in Table 1, the top disparities include six related to 30-day all-cause unplanned readmissions and four related to mortality.
(i) Measure and Stratification Groups: Variation was observed in readmissions and mortality when stratified as required by HCAI requirements for vulnerable populations. Please refer to Table 1.
(ii) Reference Group: Comparisons according to the stratified groups in the HCAI methodology can be found for each disparity in Table 1.
(iii) Rate Ratio (RR): The table highlights the differences in risk of the event between the disparity group and the reference group. This is expressed as the Rate Ratio. Please see Table 1 for the RR of each disparity group identified.
(iv) Actions, Population Impact, Objectives, and Timeframes:
SHC utilizes multidisciplinary management guidance teams (MGTs) to bring together clinical and operational leaders for clinical improvement in key areas, such as mortality, readmissions, length of stay, hospital-acquired conditions and infections, and access to care. As part of our clinical improvement structure, SHC established a Health Equity MGT that prioritizes quality improvement for actionable disparities in quality, safety, patient experience, and clinical outcomes. Stanford Medicine collaboratively developed a Health Equity Measurement Framework (HEMF) with internal and external partners to standardize data collection, stratification, analysis, and visualization. The framework enables identification of disparities, reduction in avoidable variation, and sustained improvements across populations. SHC will continue to apply the HEMF in fiscal year (FY) 2026.
Data Collection: We Ask Because We Care is a Stanford Medicine-wide initiative designed to improve the precision and completeness of patient-reported demographic data and educate patients, providers, and staff on why these questions matter. SHC will continue to leverage this initiative to better understand our patients' unique contexts that may impact their care experience and outcomes.
Readmissions: SHC focuses on reducing unplanned readmissions through a multidisciplinary, coordinated clinical improvement structure. In FY 2026, the HEMF will be applied across all patient populations to assess demographic patterns in readmissions, identify actionable variations in care, and develop interventions. For example, the Appointment Before Discharge program increases the number of hospitalized patients with timely internal and external follow-up appointments prior to discharge, supporting safe transition to home.
Mortality: SHC's measurable objective is to achieve a lower mortality rate compared to the prior fiscal year. In FY 2026, the HEMF will be applied across all patients to identify groups experiencing higher rates of mortality than expected, determine whether actionable variations in care are present, and implement interventions. Success will be evaluated through quarterly dashboards reviews, focusing on highest- and lowest-performing groups and sustained improvement.

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

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

View Fullscreen

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

Hospital Equity Measures Report Download

Click on the link below to download all equity measures reports.

6. Looking for Related Reports?