THOUSAND OAKS SURGICAL HOSPITAL, a campus of Los Robles Hosp & Med Ctr
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 MHD
|
Preferred Language | English Language | 4.7% | Spanish Language | 2.5% | 1.90 |
|
2.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 5.0% | Asian | 4.4% | 1.10 |
|
3.
CMQCC breast milk feeding
|
Preferred Language | Spanish Language | 31.7% | English Language | 34.5% | 1.10 |
2. Equity Plan
The hospital's plan to address the disparities identified in the data including population impact, measurable objectives, and specific timeframe are as follows.
MHD readmission rate disparities identified are language, over 65, visual disability. The hospital’s plan is to analyze all MHD readmission for trends and to partner with our local community resources to address identified gaps. Nurses will be encouraged help patients and family members to record the audio discharge instructions in preferred language with use of language interpreter services.
AHRQ Pneumonia mortality rate disparities identified are language, black males, over 65. The hospital's plan is to analyze trends in process measures, such as timely antibiotic administration or use of standardized order sets. Use of language interpreter services for education and plan of care, incluling family in discussions.
AHRQ PSI death disparity identified is black race/ethnicity. The hospital analyze all PSI mortalitities. The hospital will analyze trends, identify gaps, and implement targeted solutions.
Breastfeeding rate disparity identified is language. The hospital will partner with community resources and provide lactation services during prenatal period using language interpreter services. Assign lactation services to all mothers.
VBAC disparity identified is white race/ethnicity. The hospital will partner with community resources and provide education on risk associated with c-section during prenatal period.
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.