RONALD REAGAN UCLA MEDICAL CENTER

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. AHRQ PSI surgical death rate	Race and/or Ethnicity	White	235.8%	Hispanic or Latino	114.0%	2.10
2. AHRQ PSI surgical death rate	Age (excluding maternal measures)	35 to 49	250.0%	50 to 64	139.1%	1.80
3. HCAI 30-Day readmission	Expected Payor	Medicaid	20.6%	Private	11.7%	1.80
4. HCAI 30-Day readmission	Expected Payor	Medicare	18.1%	Private	11.7%	1.60
5. AHRQ PSI surgical death rate	Age (excluding maternal measures)	35 to 49	250.0%	50 to 64	139.1%	1.50
6. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	21.0%	White	13.8%	1.50
7. AHRQ PSI surgical death rate	Sex Assigned at Birth	Male	210.8%	Female	142.0%	1.50
8. CMQCC breast milk feeding	Race and/or Ethnicity	Asian	47.9%	White	68.7%	1.40
9. AHRQ pneumonia mortality rate	Sex Assigned at Birth	Male	88.7%	Female	63.9%	1.40
10. AHRQ pneumonia mortality rate	Race and/or Ethnicity	Hispanic or Latino	98.2%	White	69.1%	1.40

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2. Equity Plan

UCLA Health is committed to providing exceptional care for all, without exception. Our approach to health care equity is grounded in a targeted universalism framework that joins health equity principles with Lean Six Sigma robust performance improvement methodology to improve outcomes for all patients by addressing barriers to optimal health whenever they appear.

I. UNPLANNED READMISSIONS HEALTH EQUITY ACTION PLAN

When patients leave the hospital, we know they don't look forward to returning unexpectedly. To support patients during their transition after hospitalization, UCLA Health provides highly coordinated care and tailored post-discharge services across the patient care continuum. Nevertheless, analyses show that specific groups of UCLA patients experience higher readmission rates than expected.

Our goal is to reduce unplanned readmissions for all patients while narrowing larger-than-predicted differences among patient populations. This action plan directs proven and tailored readmission-reduction practices to patients at high risk for experiencing an unexpected repeat hospitalization within 30 days of discharge, identified using industry-standard tools and community-level risk factors.

IMPROVEMENT STRATEGIES AND MEASURABLE OBJECTIVES

By the end of 2026, we will reinforce the foundation for achieving equitable readmission outcomes:

1. Design and implement a standard process for identifying patients at high risk of readmission.
2. Develop a bundle of evidence-based readmission reduction best practices tailored to patients' needs, including social drivers of health and known risk factors associated with readmission.
3. Incorporate the bundle into electronic health record workflows to facilitate and automatically track the provision of best practices.
4. Disseminate new tools and workflows to front line care teams.

By the end of 2027, we will optimize practices for supporting patients at high risk for readmissions:

1. Develop dynamic data dashboards to track provision of the best practice bundle, overall and to subgroups of patients.
2. Aim to provide recommended best practices to at least 75% of patients at high risk of readmission.

By the end of 2028, we will aim to reduce outcome gaps between populations:

1. Apply cycles of continuous improvement to refine structures and processes, reduce gaps, and spread successful practices.
2. Aim to reduce inequities in readmission rates from severe to moderate range for groups experiencing higher-than-expected readmission rates.

II. EXCLUSIVE BREAST MILK FEEDING HEALTH EQUITY ACTION PLAN

Ronald Reagan UCLA Medical Center is designated a Baby Friendly hospital and remains committed to the breastfeeding success of every pregnant patient delivering here. This action plan addresses inequities detected in rates of Exclusive Breast Milk Feeding among specific groups of patients.

IMPROVEMENT STRATEGIES & MEASURABLE OBJECTIVES:

By the end of 2026, we will analyze the root causes of inequities in the exclusive breast milk feeding measure.

1. Routinely monitor breastfeeding outcomes across all patients and among relevant populations.
2. Deploy and analyze a postpartum survey to hear directly from delivering patients about topics including their feeding preferences and any barriers to breastfeeding
3. Investigate root causes of unexpected variations in outcomes and report findings to perinatal quality forums.

By the end of 2027, we will implement tailored interventions to improve inequities in exclusive breastfeeding.

1. Collaborate with community partners to develop strategies tailored to local needs and priorities.
2. Design processes tailored to the identified root causes of inequities in exclusive breastfeeding.
3. Implement tailored interventions and monitor delivery of optimized processes.

By the end of 2028, we aim to maintain or improve overall exclusive breastfeeding rates while narrowing or eliminating gaps among patient populations.

III. AHRQ QUALITY & SAFETY INDICATORS HEALTH EQUITY ACTION PLAN

We are committed to improving quality and safety outcomes for all patients by monitoring and addressing inequities in post-surgical and pneumonia mortality (AHRQ PSI-04 and IQI-20). Outcome differences detected among patient populations require systematic attention and ongoing analysis.

IMPROVEMENT STRATEGIES & MEASURABLE OBJECTIVES:

By the end of 2026:

1. Build and monitor dynamic displays for select quality and safety indicators to detect unexpected variations in outcomes.
2. Evaluate whether variations in outcomes are inequities and analyze root causes.
3. Report results of health equity analyses to leaders and governing bodies.
4. Develop tailored interventions and improvement plans to address significant inequities identified through continuous performance monitoring.

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

RONALD REAGAN UCLA MEDICAL CENTER