The meeting discusses the Hospital Equity Measures Report for Trinity Hospital, focusing on compliance with Assembly Bill No. 1204 and the collection of data related to health equity and patient outcomes.

Hospital Equity Measures Report Overview

The report outlines the equity measures and performance data for Trinity Hospital for the year 2024, focusing on health disparities and patient outcomes.

General information

• Report Type: Hospital Equity Measures Report

• Year: 2024

• Hospital Name: Trinity Hospital

• Facility Type: General Acute Care Hospital

• Report Period: January 1, 2024 – December 31, 2024

• Status: Submitted

• Due Date: November 29, 2025

• Last Updated: October 8, 2025

• Hospital Location with Clean Water and Air: Yes

• Hospital Web Address for Equity Report: www.mcmedical.org

Legislative context and requirements

• Assembly Bill No. 1204 mandates the collection and posting of hospital performance data regarding sociodemographic information.

• Hospitals must submit annual reports to the Department of Health Care Access and Information (HCAI).

• Reports include summaries of measures, top disparities, and equity plans to address these disparities.

Joint Commission accreditation measures

• Hospitals must report three structural measures related to health disparities and patient-centered communication.

• Trinity Hospital has a designated individual to lead health equity activities (Yes).

• A policy prohibiting discrimination is documented (Yes)

• Total patients asked about preferred language: 5,936

CMS Hospital Commitment to Health Equity

• Five domains assessed, with Trinity Hospital scoring "Yes" in Data Collection, Data Analysis, Quality Improvement, and Leadership Engagement.

• Strategic Planning domain scored "No" due to lack of attestations.

Social Drivers of Health (SDOH) reporting

• No patients aged 18 or older were screened for health-related social needs (HRSN).

• Total patients admitted: 211

• Positive screening rates and intervention rates for five HRSNs: Food Insecurity, Housing Instability, Transportation Problems, Utility Difficulties, and Interpersonal Safety all reported as zero.

Core quality measures (HCAHPS survey)

• Patient recommendation rate: 93.9% (31 of 33 respondents)

• Response rate for the survey: 23.9%

• Patients receiving written information on post-discharge symptoms: 78.8% (26 of 33 respondents)

AHRQ indicators: pneumonia mortality rate

• Data on pneumonia mortality rate is suppressed.

• In-hospital deaths and discharges with pneumonia or sepsis are not disclosed.

Surgical inpatient death rate reporting

• No data available for in-hospital deaths among surgical inpatients with serious treatable complications.

• Total surgical discharges data is not available.

Maternal Quality Care Collaborative measures

• No data reported for the Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate.

• Total number of NTSV patients and cesarean deliveries is not available.

CMQCC Vaginal Birth After Cesarean (VBAC) rate

The VBAC Rate measures the number of vaginal births per 1,000 deliveries among patients with previous Cesarean deliveries.

• The VBAC Rate is reported by various demographics including race, ethnicity, maternal age, sex, payer type, preferred language, disability status, sexual orientation, and gender identity.

• The rate is calculated using AHRQ Inpatient Quality Indicator 22 specifications.

• Data on the number of vaginal deliveries and total birth discharges with previous Cesarean deliveries is currently not available.

CMQCC Exclusive Breast Milk Feeding rate

The Exclusive Breast Milk Feeding Rate assesses the percentage of newborns who received only breast milk during their hospital stay.

• This rate is reported by demographics such as race, ethnicity, maternal age, sex, payer type, preferred language, disability status, sexual orientation, and gender identity.

• The rate is based on Joint Commission National Quality Measure PC-05 specifications.

• Data on the number of newborns exclusively fed breast milk and total newborn cases is currently not available.

HCAI all-cause unplanned 30-day hospital readmission rate

This rate indicates the percentage of unplanned hospital readmissions within 30 days for patients aged 18 and older.

• The readmission rates are stratified by eligible conditions, mental health disorders, substance use disorders, and no behavioral health diagnosis.

• Data shows zero inpatient readmissions for any eligible condition, with a total of 19 patients admitted.

• The readmission rate for patients aged 65 and older is 0%, with 0 readmissions reported for both females and males.

Health equity plan and disparities

The health equity plan outlines the hospital's approach to addressing disparities in care.

• The report identifies zero disparities among stratified measures, indicating compliance with equity reporting and privacy requirements.

• The plan includes measurable objectives and specific timeframes for addressing disparities across various priority areas.

• Priority areas include person-centered care, patient safety, addressing social drivers of health, effective treatment, care coordination, and access to care.