ADVENTIST HEALTH GLENDALE
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
|
Age (excluding maternal measures) | 65 and older | 15.1% | 18 to 34 | 5.4% | 2.80 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 14.1% | 18 to 34 | 5.4% | 2.60 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 10.7% | 18 to 34 | 5.4% | 2.00 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.9% | Private | 8.9% | 1.80 |
|
5.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Hispanic or Latino | 73.4% | White | 57.2% | 1.30 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 14.6% | Asian | 12.1% | 1.20 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 14.1% | Asian | 12.1% | 1.20 |
|
8.
HCAI 30-Day readmission
|
Preferred Language | English Language | 13.3% | Middle Eastern Languages | 11.5% | 1.20 |
|
9.
AHRQ PSI surgical death rate
|
Sex Assigned at Birth | Female | 137.5% | Male | 132.1% | 1.00 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 12.8% | Asian | 12.1% | 1.20 |
2. Equity Plan
Adventist Health is a 515-bed medical center with a long-term commitment to equitable healthcare and serving the community through Our Mission and Vision: Living God's love by inspiring health, wholeness, and hope; We will transform the health experience of our communities by improving physical, mental, and spiritual health; enhancing interactions; and making care more accessible and affordable. Community impact is at the heart of Adventist Health’s vision to transform the health experience of our communities. Adventist Health recognizes that each community has a unique set of needs. Therefore, a Community Health Needs Assessment (CHNA) is conducted to best understand the communities we serve. AHGL utilized the 2022 CHNA to build the framework for health equity initiatives. The community health priorities include: Access to Care; Health Conditions; and Mental Health. Achieving health equity is a continuous practice to ensure every individual who enters the doors of Adventist Health Glendale is treated and cared for with dignity, respect, and love.
In 2023, AHGL formalized a dynamic, multidisciplinary performance improvement team to drive coordinated efforts on health equity initiatives and social determinates of health factors. This team included representatives from Administration, Hospital Foundation, Physicians, Care Management, Pharmacy, Behavioral Health, Quality, Clinical Informatics, and Nursing. The AHGL Health Equity team developed measurable objectives from data stratified in the 2022 CHNA and determined efforts will be focused on the unhoused and mental health population groups.
Disparity 1-4 and 6-9: All-Cause, Unplanned 30-Day Hospital Readmission Rate Stratified by Age Group (excluding maternal measures); Expected Payor; Race/Ethnicity; and Preferred Language
Actions to Address Disparities Stratified by Group for Readmissions:
• Develop a care transition program for individualized disease management
• Readmission risk stratification on admission for high-risk populations with targeted interventions implemented if moderate to high risk
• Continuation of the Substance Use Navigator Program
• Implement specialized chronic disease self-management support for the older adult population
• Implement Age Friendly Measures with focused interventions based on the 4M Framework (Medication, Mentation, Mobility, and What Matters)
• Enhanced post-discharge care navigation and follow-up support
• Multidisciplinary approach to strengthen efforts for discharge planning and discharge readiness
• Partner with community programs to provide educational support on early recognition of chronic conditions, preventative medicine, access to care, and healthy living
Measurable Objectives:
• Reduce Disparity Rates of All-Cause Unplanned 30-Day Hospital Readmission Rates for age groups (65 and older; 50-64; 35-49); expected payor (Medicare); race/ethnicity groups (Black or African American; Hispanic or Latino; White); preferred language (English), respectively by 2%, within 18 months
Disparity 5: AHRQ Quality Indicator Pneumonia Mortality Rate Stratified by Race/Ethnicity
Actions to Address Disparities for Pneumonia Mortality:
• Development of an Aspiration Pneumonia Performance Improvement team
• Individualized interventions for substance use and smoking cessation counseling
• Support timely access and referrals to antibiotics and vaccination coverage
• Provide culturally appropriate care instructions and education
• Stratified data review with opportunities for improvement identified through the Mortality Review Taskforce
Measurable Objectives:
• Reduce Disparity Rate of Pneumonia Mortality in the Race/Ethnicity group: Hispanic or Latino by 2% within 18 months
Disparity 10: AHRQ Patient Safety Indicator Death Rate among Surgical Inpatients with Serious Treatable Complications Stratified by Sex Assigned at Birth
Actions to Address Surgical Death Rate:
• Mortality Review Taskforce will include review of Surgical Death cases and identify areas of opportunity
• Implement rapid cycle review of Patient Safety Indicators with detailed analysis by the Perioperative Team for opportunities to prevent recurrence
• Trended data analysis from Code Blue and Rapid Response events to include time and identification of presenting symptoms for early recognition and intervention
• Sepsis Performance Improvement Team will include review of Surgical Death cases related to the stratum of Sepsis and identify areas of opportunity
Measurable Objectives:
• Reduce Disparity Rate of Death Rate Among Surgical Inpatients with Serious Treatable Complications for females by 0.2% within 18 months
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 |
4. Web Address for Equity Report
5. Download Equity Measures Report
Click on the link below to download the equity measures report.
Click on the link below to download all equity measures reports.