(a)
All hospitals shall submit an equity report. A report shall be submitted for
each hospital plant included on a consolidated license; however, any distinct
part services shall be included in the report of the site to which they are
licensed. In accordance to Health and Safety Code Section
127373,
subdivision (d), in the equity report, all measures shall be stratified as
specified in Section 95301 to the extent the data is available, as determined
by each hospital and consistent with the California Health and Human Services
Agency's "Data De-Identification Guidelines (DDG)," dated September 23, 2016,
and hereby incorporated by reference.
(1) For
the purposes of this section, "distinct part" has the same meaning as defined
in Section
of Title
2270027 of
Title 22 of the California Code of
Regulations.
(b) All
reports must conform to the requirements of the Measures Submission Guide,
including the required specificity of each of the stratification categories in
Stratification Tables 1 and 2 of the Measures Submission Guide.
(c) For the purposes of this requirement,
reports shall include the numerator, denominator, and rate of each measure
broken down by each stratification category, to the extent the data is
available and consistent with the DDG. If the stratification group is not able
to be reported due to DDG, select "suppressed". If the data is not readily
available, leave the category blank.
(d) All hospitals shall include in their
equity report:
(1) Hospital name.
(2) Hospital HCAI ID (9 digit).
(3) Reporting organization.
(4) Report period start date [January 1 of
prior calendar year].
(5) Report
period end date [December 31 of prior calendar year].
(6) Hospital in location with access to clean
water and air, as defined by an environmental California Healthy Places Index
score of 50 percent or lower (checkbox).
(7) The web address where the hospital's
equity report, or revisions thereto pursuant to section 95308, subdivisions (e)
and (f), is published on the hospital's website. Hospitals shall meet equity
report publication requirements pursuant to Health and Safety Code Section
127373,
subdivision (a)(3).
(8) A health
equity plan that includes the following:
(A)
The top ten disparities identified in the data by the rate ratio between a
stratification group and the reference group for each measure, consistent with
the requirements included in the Measures Submission Guide.
(B) A plan to address the disparities
identified in subdivision (b)(8)(A), including population impact, measurable
objectives, and specific timeframe.
(C) Performance across all of the following
priority areas:
I. Person-centered
care.
II. Patient safety.
III. Addressing patient social drivers of
health.
IV. Effective
treatment.
V. Care
coordination.
VI. Access to
care.
(e) Equity Measures for General Acute Care
Hospitals
General acute care hospitals shall report on the following
structural measures in accordance with specifications outlined in the Measures
Submission Guide:
(1) Structural
Measures
(A) The three structural measures
based on The Joint Commission's R
3 Report:
Requirement, Rational. Reference:
I. Designate
an individual to lead hospital health equity activities.
II. Provide documentation of policy
prohibiting discrimination.
III.
Report percentage of patients by preferred language spoken.
(B) The Centers for Medicare &
Medicaid Services (CMS) Hospital Commitment to Health Equity Structural (HCHE)
Measure.
(C) CMS Screening for
Social Drivers of Health and CMS Screen Positive Rate for Social Drivers of
Health and intervention.
General acute care hospitals shall report on the following
core quality measures stratified by categories specified in Section 95301, in
accordance with specifications outlined in the Measures Submission
Guide:
(2) Core
Quality Measure
(A) Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) survey: Would recommend
hospital.
(B) HCAHPS survey:
Received information and education.
(C) Agency for Healthcare Research and
Quality (AHRQ) Quality Indicator: Pneumonia Mortality Rate.
(D) AHRQ Patient Safety Indicator: Death Rate
among Surgical Inpatients with Serious Treatable Conditions.
(E) California Maternal Quality Care
Collaborative (CMQCC) Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean
Birth Rate.
(F) CMQCC Vaginal Birth
After Cesarean (VBAC) Rate, Uncomplicated.
(G) CMQCC Exclusive Breast Milk
Feeding.
(H) HCAI All-Cause
Unplanned 30-Day Hospital Readmission Rate.
(I) HCAI All-Cause Unplanned 30-Day Hospital
Readmission Rate, stratified by behavioral health diagnosis.
(f) Equity Measures for
Children's Hospitals
Children's hospitals shall report on the following
structural measures in accordance with specifications outlined in the Measures
Submission Guide:
(1) Structural
Measures
(A) The three structural measures
based on the Joint Commission Accreditation's Health Care Disparities Reduction
and Patient-Centered Communication Accreditation Standards:
I. Designate an individual to lead hospital
health equity activities.
II.
Provide documentation of policy prohibiting discrimination.
III. Report percentage of patients by
preferred language spoken.
(B) CMS HCHE Measure.
(C) CMS Screening for Social Drivers of
Health and CMS Screen Positive Rate for Social Drivers of Health and
intervention.
Children's hospitals shall report on the following core
quality measures stratified by categories specified in Section 95301, in
accordance with specifications outlined in the Measures Submission
Guide:
(2) Core
Quality Measures
(A) Pediatric experience
survey with scores of willingness to recommend the hospital.
(B) HCAI All-Cause Unplanned 30-Day Hospital
Readmission Rate.
(g) Equity Measures for Acute Psychiatric
Hospitals
Acute psychiatric hospitals shall report on the following
structural measures in accordance with specifications outlined in the Measures
Submission Guide:
(1) Structural
Measures
(A) The three structural measures
based on the Joint Commission Accreditation's Health Care Disparities Reduction
and Patient-Centered Communication Accreditation Standards:
I. Designate an individual to lead hospital
health equity activities.
II.
Provide documentation of policy prohibiting discrimination.
III. Report percentage of patients by
preferred language spoken.
(B) CMS HCHE Measure.
(C) CMS Screening for Social Drivers of
Health and CMS Screen Positive Rate for Social Drivers of Health and
intervention.
Acute psychiatric hospitals shall report on the following
core quality measures stratified by categories specified in Section 95301, in
accordance with specifications outlined in the Measures Submission
Guide:
(2) Core
Quality Measures
(A) HCAHPS survey: Would
recommend hospital.
(B) HCAHPS
survey: Received information and education.
(C) AHRQ Quality Indicator: Pneumonia
Mortality Rate.
(D) HCAI All-Cause
Unplanned 30-Day Hospital Readmission Rate in an inpatient psychiatric facility
(IPF).
(E) HCAI All-Cause Unplanned
30-Day Hospital Readmission Rate, stratified by behavioral health
diagnosis.
(F) CMS Inpatient
Psychiatric Facility Quality Reporting (IPFQR) program Screening for Metabolic
Disorders.
(G) The Joint Commission
Substance Use Measures (SUB) SUB-3: Alcohol and Other Drug Use Disorder
Treatment Provided or Offered at Discharge and SUB-3a: Alcohol and Other Drug
Use Disorder Treatment at Discharge.
(h) Equity Measures for Special Hospitals
Special hospitals shall report on the structural and core
quality measures specified in Section 95303, subdivision (e) in accordance with
specifications outlined in the Measures Submission Guide. Special hospitals
shall report on measures where applicable.
