USC ARCADIA 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.
HCAHPS survey-received information
|
Race and/or Ethnicity | Black or African American | 64.5% | Hispanic or Latino | 89.9% | 1.40 |
|
2.
HCAHPS survey-received information
|
Disability Status | Self-Care disability | 77.2% | Does not have disability | 90.2% | 1.20 |
|
3.
HCAHPS survey-recommend hospital
|
Disability Status | Self-Care disability | 83.6% | Does not have disability | 92.2% | 1.10 |
|
4.
HCAHPS survey-received information
|
Age (excluding maternal measures) | 65 and older | 85.1% | 35 to 49 | 94.3% | 1.10 |
|
5.
HCAHPS survey-recommend hospital
|
Disability Status | Self-Care disability | 83.6% | Does not have disability | 92.2% | 1.10 |
|
6.
HCAHPS survey-received information
|
Expected Payor | Medicare | 84.4% | Private | 92.9% | 1.10 |
|
7.
HCAHPS survey-received information
|
Disability Status | Mobility disability | 82.3% | Does not have disability | 90.2% | 1.10 |
|
8.
HCAHPS survey-received information
|
Disability Status | Hearing disability | 82.5% | Does not have disability | 90.2% | 1.10 |
|
9.
HCAHPS survey-recommend hospital
|
Age (excluding maternal measures) | 50 to 64 | 86.5% | 18 to 34 | 94.4% | 1.10 |
|
10.
HCAHPS survey-received information
|
Disability Status | Vision disability | 83.0% | Does not have disability | 90.2% | 1.10 |
2. Equity Plan
USC Arcadia Hospital (USCAH), part of Keck Medicine of USC, is a 348-licensed-bed community hospital that has been serving the health care needs of patients in the San Gabriel Valley and surrounding communities for more than a century. Hospital services include 24-hour emergency room which also serves as an LA County EMS base station for the surrounding area. USCAH has a special designation as an Emergency Department Approved for Pediatrics (EDAP) and offers OB/GYN and maternity services with a neonatal ICU. USCAH offers complex neurological care and surgery as a comprehensive stroke center, cardiac care as a STEMI (heart attack) receiving center, cancer care, orthopedic care, surgical services, imaging and diagnostic services. It is the mission of USCAH to provide high-quality healing services while caring for the patient’s emotional and spiritual needs and enabling them to achieve health for life.
Action Plan:
USCAH’s analysis of the California Department of Health Care Access and Information Hospital Equity Report for calendar year (CY) 2024 highlights its commitment to equitable patient care, as the Top 10 Disparities report did not uncover substantial variations between patient populations. Analysis highlighted opportunities to improve patient experience; particularly when receiving written information and education upon discharge and likelihood to recommend.
Variances in readmissions and patient experience are tracked to understand opportunities to ensure the highest quality of care and patient experience for all patients. Insights from these data guide targeted interventions, continuous quality improvement, and accountability across the hospital. To address the opportunities identified in patient understanding of discharge instructions, USCAH is enhancing its multifaceted, hospital-wide approach to patient care and experiences. These processes are designed to support patients, strengthen care coordination, and ensure that all interventions are aligned with organizational priorities: high quality person-centered care, patient safety, effective treatment, access to care, and attention to the social drivers of health in support of physical and spiritual wellness.
Key processes include:
Screening for Social Drivers of Health (SDOH)
Standardized Discharge Education
Post-Discharge Follow-Up As Needed
Multidisciplinary Care Coordination
Patient and Family Feedback Integration
Culturally Intelligent Care program
Age Friendly Framework Adoption
Variance Monitoring
Collectively, these efforts are designed to reduce variances, improve clinical outcomes, and enhance the overall patient experience. By leveraging data-driven insights, patient feedback, and ongoing evaluations, USCAH is able to measure progress, identify emerging opportunities, and continuously refine interventions. The result is a healthcare environment where every patient receives high-quality, safe, and personalized care, every time, and where the organization can be confident that improvement initiatives are creating meaningful, measurable impact for all patients.
Measuring Success
USCAH has an existing interprofessional structure to review stratified clinical data, patient experience data, and operational metrics. This enables the hospital to identify and address key opportunities to reduce barriers to care, improve quality and safety practices, and strengthen care coordination—especially for patients with age-related variances or social challenges that impact health outcomes.
To ensure that improvement efforts achieve their intended outcomes without creating unintended consequences, USCAH monitors a comprehensive set of success measures. Hospital leadership and quality committees review stratified data regularly, and patient and family insights are incorporated to guide refinements. This structured oversight ensures that interventions are effective, sustainable, and aligned with the hospital’s goals of reducing disparities, improving outcomes, and delivering exceptional care experiences. Progress on improvement plans is evaluated at 30-, 60-, and 90-day intervals, and will be measured throughout calendar year 2026.
Key measures include:
Readmission Rates
Patient Experience Measures
SDOH Screening Rates
Targeted Service Line and Population Performance
Adverse Events and Safety Incidents
By monitoring these measures alongside other outcomes and process interventions, USCAH is able to continuously refine care delivery, anticipate patient needs, and address barriers proactively. This approach ensures that improvement initiatives not only reduce variances and readmissions but also enhance the overall patient experience, promote safety, and strengthen care coordination, reflecting the hospital’s commitment to high-quality, person-centered care.
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.