SHERMAN OAKS HOSPITAL

4929 VAN NUYS BOULEVARD, SHERMAN OAKS, CA 91403
HCAI ID
106190708
Reporting Organization
SHERMAN OAKS HOSPITAL
Report Period
01/01/2024 – 12/31/2024
Hospital / Hospital System
Hospital
Report Type
General Acute Care Hospital
License No
930000149
Licensee
PRIME HEALTHCARE SERVICES-SHERMAN OAKS, LLC
County
Los Angeles

System Report

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
Age (excluding maternal measures) 35 to 49 21.7% 18 to 34 10.0% 2.20
2. HCAI 30-Day readmission
Expected Payor Medicare 19.6% Private 9.9% 2.00
3. HCAI 30-Day readmission
Age (excluding maternal measures) 65 and older 19.0% 18 to 34 10.0% 1.90
4. HCAI 30-Day readmission
Expected Payor Medicaid 16.8% Private 9.9% 1.70
5. HCAI 30-Day readmission
Age (excluding maternal measures) 50 to 64 16.1% 18 to 34 10.0% 1.60
6. HCAI 30-Day readmission NOBH
Sex Assigned at Birth Male 19.9% Female 14.9% 1.30
7. HCAI 30-Day readmission
Sex Assigned at Birth Male 20.0% Female 16.5% 1.20
8. HCAI 30-Day readmission
Race and/or Ethnicity Hispanic or Latino 20.6% White 17.7% 1.20
9. HCAI 30-Day readmission
Race and/or Ethnicity Black or African American 20.6% White 17.7% 1.20

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2. Equity Plan

Age
Patients 35 to 49, 50 to 64, and greater than or equal to 65 had higher readmission rates (15.4 to 19.8) compared to younger adults 18 to 34 (9.2).
Insurance (Payor)
Medicare (19.1) and Medicaid (15.5) patients had higher readmissions compared to private insurance (9.3)
Sex at Birth
Males (19.4) had higher readmissions than females (14.5 to 15.7)
Race or Ethnicity
Hispanic or Latino (19.8) and Black or African American (18.8) patients had higher readmissions compared to White patients (17.1)
Planned Actions.
Launch targeted patient education on medication management and follow-up visits, with bilingual staff for Spanish speaking patients
Strengthen partnerships with community clinics for improved transition of care
Implement case management outreach for Medicare or Medicaid beneficiaries before discharge
Track disparities quarterly and report outcomes to leadership
Objectives
Reduce age 35 to 49 readmissions from 19.8% to less than 16.5% by Q4 FY2026
Reduce greater than or equal to 65 readmissions from 18.5% to less than 15.5%
Reduce 50 to 64 readmissions from 15.4% to less than 13.5%

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

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4. Web Address for Equity Report

https://shermanoakshospital.org/

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

Hospital Equity Measures Report Download

Click on the link below to download all equity measures reports.

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