SHARP MEMORIAL 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
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 21.0% | White | 13.7% | 1.50 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 16.8% | Private | 11.2% | 1.50 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.5% | Private | 11.2% | 1.40 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 15.4% | 35 to 49 | 11.8% | 1.30 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.5% | White | 13.7% | 1.30 |
|
6.
AHRQ PSI surgical death rate
|
Age (excluding maternal measures) | 50 to 64 | 224.5% | 65 and older | 177.8% | 1.30 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 14.0% | 35 to 49 | 11.8% | 1.20 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 18 to 34 | 13.3% | 35 to 49 | 11.8% | 1.10 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 15.2% | White | 13.7% | 1.10 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 14.4% | White | 13.7% | 1.10 |
2. Equity Plan
Sharp Memorial Hospital is actively working to advance health equity through strategic initiatives. The hospital collaborates with Sharp Healthcare on both entity-specific and system-wide efforts. These initiatives focus on identifying priority populations experiencing health disparities, setting health equity goals, developing action plans to achieve these goals, and engaging key stakeholders across the organization. This comprehensive approach aims to address and reduce health disparities especially as it relates all cause 30-day readmissions and patient safety indicators. Sharp Memorial's top ten disparities identified nine opportunities to address readmissions by race, ethnicity, age, and payor and one opportunity to address death rates among surgical complications for elective procedures by age. All rate ratios identified are quite low with all under a value of 2, with the highest rate ratio at 1.5. With the lower the rate preferred, Memorial's readmission disparities have some opportunities for improvement but overall are doing well. The top disparities identified reveal multi-racial or multi-ethnic patients are readmitted one and a half times more than their white counterparts. Medicaid and Medicare higher than private payors and age seems to be a factor but variable. Sharp Memorial has a comprehensive approach to addressing readmissions through an interdisciplinary readmission taskforce committee represented by all hospital disciplines and services. Even though the data reveals a rate ratio of 1.5 for multi-racial and multi-ethnic readmissions compared to white patients, this data matches our inpatient volumes of each group. That said, with increased screening for social determinants of health to a compliance of greater than 85% in recent months, leaders can now create a more comprehensive plan down to the individual unit level, addressing this disparity with enhanced data visibility. An example of this includes how one of our surgical units identified a gap in post operative education related to a language barrier and cultural beliefs. The team quickly created additional education materials, ensuring proper utilization of the materials leading to a reduction in readmissions over the past several months. Sharp Healthcare establishes annual target goals to lower both 30-day and 7-day readmissions, utilizing an entity specific taskforce that concentrates on high-risk patient populations and disease-specific strategies. Since the taskforce's inception, our 7 -day readmissions have decreased from 4.34% in September 2024 to 3.41 % at the end of June 2025. Sharp Memorial is planning to implement several strategies to improve patient care post-discharge. These strategies include increasing the use of discharge phone calls to assess patient needs, expanding discharge prescription services to all high-risk patient populations, and enhancing referrals to outpatient providers or clinics with secured follow-up appointments. These initiatives aim to prevent complications and ensure continuity of care for patients after they leave the hospital.
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.