TARZANA TREATMENT 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.
CMS IPFQR screening metabolic disorders
|
Race and/or Ethnicity | Black or African American | 29.2% | Hispanic or Latino | 10.4% | 2.80 |
|
2.
CMS IPFQR screening metabolic disorders
|
Sexual Orientation | Don’t know | 33.3% | Straight or heterosexual | 14.3% | 2.30 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 28.1% | Middle Eastern or North African | 14.9% | 1.90 |
|
4.
CMS IPFQR screening metabolic disorders
|
Expected Payor | Medicare | 24.0% | Private | 13.9% | 1.70 |
|
5.
HCAI 30-Day readmission SUD
|
Race and/or Ethnicity | Black or African American | 13.2% | Hispanic or Latino | 7.7% | 1.70 |
|
6.
HCAHPS survey-recommend hospital
|
Age (excluding maternal measures) | 35 to 49 | 82.0% | 65 and older | 100.0% | 1.20 |
|
7.
HCAHPS survey-recommend hospital
|
Expected Payor | Medicaid | 86.0% | Medicare | 92.0% | 1.10 |
|
8.
HCAHPS survey-recommend hospital
|
Race and/or Ethnicity | Hispanic or Latino | 85.0% | Black or African American | 92.0% | 1.10 |
|
9.
HCAHPS survey-recommend hospital
|
Sex Assigned at Birth | Female | 84.0% | Female | 87.0% | 1.00 |
2. Equity Plan
Disparity: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey
Population Impact: Disparities exist among patient population in recommending IPF to friends and family. Payer Type (Medicare) appears to be an important factor to recommend the hospital to other people followed by age group (65 and Older), race/ethnicity (Middle Eastern or North African) and sex assigned at birth (Female). Train staff in the delivery of excellent customer service and providing exceptional hospital patient experience to all patients served.
Measurable Objectives: In the next 12 months, a minimum of 70% of Hospital patients served will report in Perception of Care (POC) Survey that they are recommending hospital to friends and family.
Timeline: January - December 2026
Disparity: HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate in IPF
Population Impact: Disparities including race and/or ethnicity (overall and stratified by SUD) and sexual orientation (stratified by no behavioral health diagnosis) impact unplanned 30-day Hospital readmission rate. Among the patient population, those that indicate being Straight/Heterosexual, Multiracial and/or Multiethnic, or Black/African American tend to contribute to unplanned readmission rate. The IPF staff including medical staff, counselors, and behavioral health staff will be trained to improve discharge planning, care coordination and addressing patient needs prior to discharge. Patient unplanned 30-day hospital readmissions will be tracked on a monthly/quarterly basis and reported to hospital leadership.
Measurable Objectives: In the next 12 months, unplanned 30-day hospital readmission rate will be reduced.
Timeline: January - December 2026
Disparity: CMS Inpatient Psychiatric Facility Quality Reporting (IPFQR) program Screening for Metabolic Disorders
Population Impact: Disparities exist among patient populations with differing sexual orientations, race/ethnicity, and payer type. Patients that indicate Don't Know as their sexual orientation, are Black/African American, or use Medicare tend to receive a metabolic screening after being discharged with an antipsychotic medication. The IPF needs to provide all patients access to metabolic screening while in treatment. A Metabolic Screening Checklist will be developed and implemented with all Hospital patient groups. Metabolic Screening will be tracked on a monthly/quarterly basis and reported to hospital leadership.
Measurable Objectives: In the next 12 months, at least 90% of patients will have received metabolic screening.
Timeline: January - December 2026
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.