GROSSMONT HOSPITAL
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
|
Expected Payor | Medicare | 17.0% | Other | 8.8% | 3.90 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 15.2% | Other | 8.8% | 3.50 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Private | 10.4% | Other | 8.8% | 2.40 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 17.8% | 18 to 34 | 8.1% | 2.20 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.4% | 18 to 34 | 8.1% | 2.00 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 13.5% | 18 to 34 | 8.1% | 1.70 |
|
7.
AHRQ PSI surgical death rate
|
Age (excluding maternal measures) | 50 to 64 | 271.2% | 65 and older | 165.1% | 1.60 |
|
8.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 52.0% | Female | 32.8% | 1.60 |
|
9.
AHRQ PSI surgical death rate
|
Sex Assigned at Birth | Female | 218.8% | Male | 147.1% | 1.50 |
|
10.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | White | 50.6% | Hispanic or Latino | 35.0% | 1.40 |
2. Equity Plan
Sharp Grossmont Hospital is situated in the east county (ECR) region of San Diego and serves a
diverse patient population - approx. 29% Hispanic and 53.8% non-Hispanic white per the 2023
San Diego County census report.
The disparity report for Sharp Grossmont Hospital (SGH) identified a total of 6 out of 10 disparities
relating to readmissions in the following populations: Payors - Medicare, Medicaid and Private, Age/s
35 to >/= 65 years. The remaining 4 disparities are centered on Center for Medicare and Medicaid
Services (CMS) patient safety indicator (PSI) 4 postsurgical mortality for the age group 50-64 and
female patient populations and for postoperative pneumonia (PNA) mortality for male/white
population/s.
Sharp Grossmont Hospital (SGH) is committed to advancing health equity through strategic, datainformed initiatives that align with Sharp HealthCare's system-wide efforts. SGH's health
equity strategy focuses on identifying priority populations, setting actionable annual goals, and
implementing targeted interventions to reduce disparities in outcomes including the ones identified
above. SGH collaborates closely with Sharp HealthCare to align its efforts with system-wide equity
goals. The hospital uses Sharp's equity dashboard to monitor disparities and guide strategic
planning. SGH's proactive approach includes embedding equity into clinical workflows,
leveraging technology to support patient education, and strengthening partnerships with community
organizations.
A cornerstone of SGH's equity work is its Geriatric Emergency Department Accreditation
(GEDA) program, which has achieved Level 1 Gold Standard recognition for two consecutive years.
This program ensures that emergency care is tailored to the unique needs of older adults through
age-sensitive protocols, staff training, and environmental modifications. It promotes early
identification of geriatric syndromes and facilitates connections to outpatient services and
community resources, supporting safer transitions of care and reducing avoidable hospitalizations.
SGH has implemented several innovative strategies to improve discharge planning and reduce
readmissions. Discharge education begins on the first day of admission, supported by technology s
uch as iPads and virtual nursing pilots on select units. These tools enable real-time engagement, all
owing patients to receive timely education and support throughout their stay. In-hospital bedside ed
ucation is reinforced by SGH's pharmacy team, which plays a critical role in medication
reconciliation and ensures patients leave with medications in hand through the Discharge
Prescription Services program. To further support medication access, SGH offers Project HELP, a
program that provides free prescriptions to under- and uninsured patients. This initiative addresses
financial barriers and supports medication adherence, particularly for patients facing transportation
challenges or housing insecurity - factors that are prevalent in East County and contribute to
health disparities.
Surgical outcomes are closely monitored through internal dashboards that track performance by
specialty and provider. These dashboards inform multidisciplinary reviews and guide improvements
in patient safety indicators and mortality measures. A structured three-tiered review process -
spanning quality, coding, and clinical documentation - ensures that each case is examined for
opportunities to enhance care delivery and system learning. The use of interdisciplinary enhanced
recovery after surgery (ERAS) pathways are used by the various surgical disciplines to prevent
complications after surgery.
SGH's certified Sepsis Program exemplifies its commitment to targeted, high-impact
interventions that reduce mortality. Components of the program include early identification and
intervention for sepsis patients by leveraging SGH's electronic health record system to trigger
rapid response protocols. The program traverses the inpatient setting to include post-discharge
follow up calls, patient education and home care toolkits - including thermometers and symptom
checklists - to support recovery and prevent complications.
SGH is committed to advancing its mission to deliver high-quality, patient-centered care to every
individual it serves. The hospital remains focused on closing gaps in care, reducing disparities, and
fostering a culture of inclusion and belonging across all levels of the organization
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 |
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.