UCLA WEST VALLEY 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.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 18.9% | Hispanic or Latino | 10.4% | 1.80 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.3% | Private | 9.6% | 1.70 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.9% | 18 to 34 | 9.1% | 1.60 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 14.8% | 18 to 34 | 9.1% | 1.60 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 16.2% | Hispanic or Latino | 10.4% | 1.60 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 13.3% | 18 to 34 | 9.1% | 1.50 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.8% | Hispanic or Latino | 10.4% | 1.40 |
|
8.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 12.7% | Private | 9.6% | 1.30 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 13.2% | Hispanic or Latino | 10.4% | 1.30 |
|
10.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Female | 14.4% | Male | 12.5% | 1.20 |
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.
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.
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.