LOMA LINDA UNIV. MED. CENTER EAST CAMPUS HOSPITAL

1. Top 10 Disparities

2. Equity Plan

LOMA LINDA UNIVERSITY MEDICAL CENTER EAST CAMPUS Hospital maintains a multidisciplinary Healthcare Equity Task Force responsible for reviewing, validating, and addressing disparities identified through HCAI data stratification. This team includes clinical leaders, quality specialists, care management, infection prevention, patient experience, and operational partners. The task force provides system oversight for the hospital equity work and ensures alignment with organizational quality and safety goals. Our action plan is as follows: 1. Data Validation & Deeper Analysis For each disparity: • Analysts perform deeper stratification when needed (e.g., adding LOS, payer, unit-level detail) to understand where variation is occurring. • Teams may request chart review samples or pull additional encounter-level data if needed. • If the variance appears influenced by structural, clinical practice, or workflow factors, those issues are flagged early for deeper inquiry. • To ensure the greatest impact, the Task Force where necessary will narrows the scope to the specific processes, populations, or units where targeted intervention will yield the most meaningful and measurable improvement. 2. Root Cause Analysis (RCA) Once the disparity is validated, a targeted RCA is completed: • Engagement of clinical leaders and frontline staff from affected areas (ED, OB, Adult Medicine, Surgery, etc.). • Examination of contributing factors across People, Process, Equipment, Environment, Documentation, and Policy/Workflow domains. • Assessment of: o Documentation quality and completeness o Timeliness and appropriateness of clinical interventions o Barriers related to communication, health literacy, or language o Staffing or resource constraints o Variation in clinical workflows or adherence to standards Findings guide the development of focused, high-impact improvement strategies. 3. Development of Improvement Interventions Following RCA, the Task Force designs targeted interventions tailored to the drivers of the disparity: • Development of workflow, structural, or clinical practice changes that directly address identified gaps. • Prioritization of interventions based on: o Population impact o Feasibility and resource needs o Alignment with system priorities o Strength of evidence and ability to meaningfully influence the RR This ensures interventions are both strategic and operationally realistic. 4. Implementation & PDSA Cycles Interventions are implemented using PDSA cycles (Plan–Do–Study–Act): • Plan: Define specific change, target population, expected measurable improvement. • Do: Pilot the intervention in a controlled area or with a defined population. • Study: Review impact using early data (30-, 60-, 90-day windows). • Act: o If effective - scale hospital-wide o If not yielding desired results - modify the action plan and retest Multiple PDSA cycles may run concurrently depending on the complexity of the disparity. 5. Monitoring, Measurement & Outcome Validation During the 3–6 month validation window, East Campus Hospital continues to use theLLUH Health Care Equity Dashboard and the Dexur/HCAI Measure Dashboard to monitor real-time changes in rate ratios (RRs), evaluate the effectiveness of implemented interventions, and detect early signs of improvement or regression. These dashboards support ongoing measurement by displaying stratified trends, outcome trajectories, and adherence to new workflows. If improvement plateaus or RR gaps persist, dashboard analytics inform modifications to the action plan and additional RCA cycles. 6. Timeframe for Disparity Reduction Based on organizational capacity and industry-standard quality improvement timelines: • Each disparity improvement cycle is planned over 18–24 months (from validation - RCA - intervention - PDSA - reassessment - sustained improvement). • Earlier improvements will be reported if achieved sooner 7. Leadership Visibility and Governance Structure To ensure shared accountability and executive alignment, the Healthcare Equity Task Force follows a clearly defined reporting structure: • Reporting to the Health Care Equity Committee: o The Task Force provides regular updates on identified disparities, RCA findings, proposed interventions, and progress toward outcome improvement. o The Health Care Equity Committee reviews each facility’s action plans, ensures methodological rigor, and aligns improvement work with systemwide equity priorities. • Escalation to the Hospital Quality Committee of the Board: o The Health Care Equity Committee reports its findings, trends, and recommendations to the Hospital Quality Committee of the Board. • Shared Accountability Across Leadership Layers: o Frontline improvement efforts are supported and monitored by executive and board leadership. o Equity performance is treated as a core quality and patient safety responsibility, not a standalone project.

3. Structural Measures

5. Download Equity Measures Report

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6. Looking for Related Reports?

• Hospital Profile
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