Cal. Code Regs. Tit. 22, § 95304 - Hospital System Equity Report
(a) A hospital system, as defined in Section
95300, shall submit a hospital system equity report.
(b) A hospital system shall include in their
hospital system equity report:
(1) Hospital
system name.
(2) Hospital system
CEO (or equivalent).
(3) Hospital
system ID (as generated by HCAI reporting system).
(4) System description.
(5) Report period start date [January 1 of
prior calendar year].
(6) Report
period end date [December 31 of prior calendar year].
(7) 9-digit HCAI IDs of hospitals included in
hospital system report.
(8) Grouped
by hospital type, aggregate data from each of their hospitals, consistent with
the requirements of the Measures Submission Guide. Hospital system equity
reports shall include the numerator, denominator, and rate of each core measure
broken down by each stratification category, to the extent the data is
available and consistent with the DDG. If the DDG prohibits reporting of a
stratification group, "suppressed" shall be selected. If the data is not
available, the category shall be left blank. Hospital system equity reports
shall report on all hospital core measures outlined in Section 95303. All
structural measures outlined in Section 95303 shall also be reported except for
the CMS HCHE Measure.
(9) A
hospital system 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 each of the ten disparities identified in subdivision (b)(9)(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 determinants of health.
IV.
Effective treatment.
V. Care
coordination.
VI. Access to
care.
(c) A hospital system equity report is not a
substitute for an individual hospital equity report. An equity report, as
specified in Section 95303 must be submitted by each hospital.
(d) A hospital system shall post the hospital
system's equity report, or revisions thereto pursuant to section 95308,
subdivisions (e) and (f), on the hospital system's website, if one is
available. A hospital system may include in the equity report the web address
where the hospital system's equity report is published. Report publication on
the hospital system's website shall meet the requirements stated in Health and
Safety Code Section
127373,
subsection (a)(3).
Notes
Note: Authority cited: Section 127375, Health and Safety Code. Reference: Sections 127372 and 127373, Health and Safety Code.
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