VALLEY CHILDREN’S HOSPITAL

9300 VALLEY CHILDREN'S PLACE, MADERA, CA 93636
HCAI ID
106204019
Reporting Organization
Valley Children's Hospital
Report Period
01/01/2024 – 12/31/2024
Hospital / Hospital System
Hospital
Report Type
Children's Hospital
License No
040000160
Licensee
VALLEY CHILDREN'S HOSPITAL
County
Madera

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
Race/Ethnicity White 6.6% Black or African American 3.7% 1.80
2. HCAI 30-Day readmission
Age 15 years and older 8.7% 0–4 years 5.2% 1.70
3. HCAI 30-Day readmission
Race/Ethnicity Hispanic or Latino 6.0% Black or African American 3.7% 1.60
4. HCAI 30-Day readmission
Race/Ethnicity Asian 5.7% Black or African American 3.7% 1.60
5. HCAI 30-Day readmission
Expected Payor Medicaid 6.6% Private 4.3% 1.50
6. HCAI 30-Day readmission
Age 5–9 years 6.4% 0–4 years 5.2% 1.20
7. Pediatric survey recommend hospital
Expected Payor Self-Pay 76.5% Medicaid 89.8% 1.20
8. Pediatric survey recommend hospital
Race/Ethnicity American Indian or Alaska Native 85.4% Native Hawaiian or Pacific Islander 98.4% 1.20
9. HCAI 30-Day readmission
Age 10–14 years 5.9% 0–4 years 5.2% 1.10
10. Pediatric survey recommend hospital
Race/Ethnicity Black or African American 87.1% Native Hawaiian or Pacific Islander 98.4% 1.10

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2. Equity Plan

Seven of the 10 disparities identified at Valley Children’s were related to the California Department of Health Care Access and Information (HCAI) All-Cause 30-Day Readmission Rate, with the top disparities occurring among the age and race and/or ethnicity stratification groups. While the calculated rate ratios suggest a possible disparity, chart review of individual cases found no evidence of inappropriate or substandard care. These results can be attributed to the efforts of our Health Equity Steering Committee, which was established to analyze clinical outcomes and identify potential disparities. As part of their ongoing work, the committee monitors hospital readmissions to ensure care is both appropriate and effective. To date, no disparities in clinical outcomes have been found.

To reduce and prevent disparities within readmission rates, several best practices have been implemented hospital wide. These include scheduling follow-up appointments prior to discharge, developing care plans for high-risk patients, conducting post discharge follow-up calls to high-risk patients, providing patients with clear and understandable discharge instructions in their native language, and explaining potential problems and what to do or who to contact if a problem arises. We ensure our patients understand their discharge instructions thoroughly before leaving the hospital via return demonstration when applicable. As part of our continuous and never-ending improvement, the Quality and Performance Improvement team reviews same-cause hospital readmissions weekly to ensure the care during the initial hospitalization was appropriate. Metrics being tracked to monitor potential disparities include health conditions, race/ethnicity, Child Opportunity Index (COI) and payer status.

We are confident in the care we provide for our patients and their families regardless of race or ethnicity, as evidenced by the results of our pediatric experience survey which showed little to no disparities when comparing race. Over the next 12 months, we will maintain our efforts by applying best practices and tracking outcomes to ensure care remains equitable, safe, effective, timely, efficient and patient centered.

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

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4. Web Address for Equity Report

https://www.valleychildrens.org/

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.

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