Central Valley Doctors Health System, Part of Tenet Healthcare System

CENTRAL VALLEY DOCTORS HEALTH SYSTEM

Reporting Organization
CENTRAL VALLEY DOCTORS HEALTH SYSTEM
Report Period
01/01/2024 – 12/31/2024
Hospital / Hospital System
Hospital System
Report Type
General Acute Care Hospital

Hospitals

Hospital Count: 3

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. CMQCC NTSV cesarean rate
Age (for maternal measures only) 30 to 39 0.4% 18 to 29 0.2% 2.30
2. AHRQ PSI surgical death rate
Age (excluding maternal measures) 65 and older 325.6% 50 to 64 173.3% 1.90
3. AHRQ PSI surgical death rate
Expected Payor Medicare 315.4% Medicaid 181.8% 1.70
4. AHRQ PSI surgical death rate
Race and/or Ethnicity White 274.5% Hispanic or Latino 168.2% 1.60
5. CMQCC NTSV cesarean rate
Preferred Language English Language 0.3% Spanish Language 0.2% 1.60
6. CMQCC breast milk feeding
Preferred Language Spanish Language 28.7% English Language 45.5% 1.60
7. CMQCC breast milk feeding
Expected Payor Medicaid 37.6% Private 56.7% 1.50
8. CMQCC NTSV cesarean rate
Expected Payor Private 0.3% Medicaid 0.2% 1.40
9. CMQCC VBAC rate
Age (for maternal measures only) 30 to 39 99.3% 18 to 29 135.6% 1.40
10. AHRQ pneumonia mortality rate
Race and/or Ethnicity White 61.3% Hispanic or Latino 47.4% 1.30

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2. Equity Plan

Disparity Identified: Higher Rate Ratio (RR) of NTSV Cesarean births among women aged 30–39, English-speaking, and in the private payer group compared with the reference group. Actions Planned: We will implement the AIM (Alliance for Innovation on Maternal Health) Patient Safety Bundle for the "Safe Reduction of Primary Cesarean Birth" across all system birthing centers. Key actions include: Implementing a standardized Labor Dystocia Checklist in the EHR to ensure diagnostic criteria are met before a cesarean section is ordered and huddles between nursing and obstetric staff for every patient who enters the second stage of labor to discuss physiologic support. Population Impact: This initiative targets all first-time, low-risk birthing individuals in the disparity group. Measurable Objectives: Reduce the failure rate of standardized rapid-response triggers by 5% for the target demographic from 27.3% by the end of the reporting cycle through Maternal Early Warning Signs (MEWS) integration. Specific Timeframe: Q1 2026: Standardize EHR checklists across all facilities. Q2 2026: Complete staff training on AIM bundles and cultural humility in labor management. Q4 2026: Conduct system-wide audit of checklist compliance and RR reduction. Disparity Identified: Patients who are English-speaking and privately insured achieve significantly higher exclusive breast milk use compared with patients who are non-English-speaking, publicly insured, or from historically marginalized populations. Early, uninterrupted skin-to-skin contact and initiation of breastfeeding within the first hour of life (“Golden Hour”) is recommended by World Health Organization and the American Academy of Pediatrics as a core strategy to improve breastfeeding initiation, exclusivity, and duration. Standardizing Golden Hour practices reduces variation in care that disproportionately impacts non-English-speaking and publicly insured patients. Actions planned: Implement a market-wide Golden Hour protocol requiring uninterrupted skin-to-skin contact and breastfeeding initiation within the first 60 minutes of life for all clinically stable mother–infant dyads, regardless of delivery location, language, or payor status. This will include immediate skin-to-skin contact initiated within 5 minutes of birth, delay non-urgent newborn care (weights, baths, medications) until after the Golden Hour, breastfeeding initiation supported during the first hour with nursing or lactation assistance, and language-concordant education and interpreter support during Golden Hour. We will also join the Stanislaus Breastfeeding Coalition to provide ongoing education, collaboration, and best-practice support for the Maternal–Child Health lactation and nursing leadership teams. Population Impact: This initiative targets populations including non-English speaking and publicly insured patients, and those experiencing social, cultural or systemic barriers to breastfeeding. We estimate this will improve care for patients annually across our system. Measurable Objectives: Increase exclusive breast milk feeding at discharge to 60% from baseline across the market within 12 months. Achieve =90% compliance with documented Golden Hour practices for eligible mother–infant dyads within 6 months. Specific Timeframe: Q1 2026: Implicit Bias & Respectful Maternity Care: Education addressing unconscious bias in feeding recommendations and documentation to reduce disparities in exclusive breastfeeding support. Course: Intersecting Identities and Bias in Prenatal Care. Q2 2026: Initiation of Golden Hour across market. Q3 2026: Lactation Skills & Competency Validation: Annual skills-based training on latch assessment, hand expression, supplementation avoidance, and early identification of feeding challenges. Disparity Identified: Lower VBAC success rates for patients aged 30-39 compared to the reference group. Actions Planned: Implement a system-wide VBAC Support & Access Initiative based on CMQCC toolkits, establish a system-level "On-Call Laborist" model to ensure 24/7 immediate cesarean capability (anesthesia and surgical staff) is guaranteed for any patient undergoing TOLAC, removing the "safety concern" barrier often cited for vulnerable populations, and provide blinded, stratified reports to OB/GYN leads showing their TOLAC "offer rates" by patient race and language to identify and correct unconscious bias in counseling. Population Impact: This targets patients with one prior low-transverse cesarean incision. Measurable Objectives: Increase TOLAC Attempt Rate for the target demographic by 10%. Reduce percentage for VBAC failure from 40% to 30% within 18 months. Specific Timeframe: Q2 2026: Complete training for L&D nursing staff on supporting physiologic labor for TOLAC patients. Q4 2026: Review first-year data. For disparities identified in PSI-4 (death rate among surgical inpatients with serious treatable complications) and PSI-10 (pneumonia mortality), see Doctors Medical Center's plan

3. Web Address for Equity Report

https://www.cvdoctorshealthsystem.com/health-equity

4. 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.