CHILDREN’S HOSPITAL AT MISSION
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.
Pediatric survey recommend hospital
|
Expected Payor | Other | 80.2% | Medicaid | 91.6% | 1.10 |
|
2.
Pediatric survey recommend hospital
|
Expected Payor | Private | 83.0% | Medicaid | 91.6% | 1.10 |
|
3.
Pediatric survey recommend hospital
|
Age | 0–4 years | 81.7% | 15 years and older | 87.6% | 1.10 |
2. Equity Plan
Overview and Findings
The hospital-level analysis of AB 1204 equity measures for Calendar Year 2024 at Children’s Hospital at Mission, part of Rady Children’s Health, identified disparities in willingness to recommend (WTR) the hospital by payor type and age. Due to the overall small patient volume, the analysis uncovered three disparities across both hospital equity measures reported for pediatric core quality measures: the 30-day all-cause readmission rate and the pediatric experience survey with scores of willingness to recommend the hospital. The current age disparities at Rady Children’s Hospital Mission are understood to be largely driven by patients in our specialty programs: the Eating Disorder Medical Stabilization Program and the Pediatric Intensive Care Unit (PICU).
Key Disparities & Insights
Pediatric Experience Survey with Scores of Willingness to Recommend the Hospital
* Expected Payor: Families of patients insured through Medicaid showed a higher WTR rate of 91.6%, compared to families of patients insured through other insurance at 80.2% and private insurance at 83.0% (both RR 1.1).
* Age: Families of patients aged 15 years and older showed a higher WTR score of 87.6% compared to families of patients aged 0-4 years at 81.7% (RR 1.1).
Strategic Interventions
1. Data & Predictive Modeling
* Continue enterprise-wide demographic and condition data collection for deeper analysis.
* Conduct multivariate studies to clarify observed discrepancies.
* Refine risk models to include social factors and language to identify high-risk discharges.
2. Workforce & Governance
* Socialize disparity data through medical staff town halls, nursing forums, and leadership committee , etc.
* Build a system-wide learning network to share effective interventions and data insights.
* Embed equity metrics into Quality and Safety dashboards and scorecards.
3. Leverage Trust to Drive Outcomes
* Launch a patient experience survey campaign to strengthen WTR among groups experiencing disparities.
* Use high WTR and low WTR to invite families into co-design, highlight successful family stories, and activate community advocates to increase organizational health literacy.
4. Targeted Discharge & Follow-Up Pathways
* Improve discharge education with health literacy strategies and interpretation tools, including “Say-It-Simply, ” teach-back, and visual tools.
* Promote the free CHOC Nurse Line , available with Spanish-speaking staff and interpreter services, to support post-discharge guidance to reduce avoidable readmissions.
5. Patient-Focused Chronic Care Strategies
* Develop simplified care plans and digital reminders to support adherence.
* Engage families and schools in chronic disease management, including adolescent transition supports.
6. Community & System Partnerships
* Connect families with community health workers and navigators for appointment access, care adherence, and home support.
* Leverage school and community partnerships for education and linkage to care, including social needs.
Measurement & Targets
* Implement quarterly equity dashboards tracking WTR by race, language, payor, age, and diagnosis.
* Adopt strategies to reduce the WTR gap between patients insured through Medicaid and private payors in the next reporting cycle while maintaining or improving WTR among high-reporting groups.
Conclusion
By centering discharge planning, health literacy, and targeted follow-up, data-driven insights, community partnerships, and accountable governance, Children’s Hospital at Mission, part of Rady Children’s Health, can sustain high-quality, patient-centered experiences for all populations.
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 |
No |
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 |
No |
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.