USC VERDUGO HILLS 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
|
Expected Payor | Medicare | 81.6% | Private | 97.0% | 1.20 |
|
2.
HCAHPS survey-received information
|
Age (excluding maternal measures) | 65 and older | 82.3% | 18 to 34 | 94.0% | 1.10 |
|
3.
HCAHPS survey-received information
|
Age (excluding maternal measures) | 50 to 64 | 85.9% | 18 to 34 | 94.0% | 1.10 |
|
4.
HCAHPS survey-recommend hospital
|
Age (excluding maternal measures) | 50 to 64 | 88.1% | 65 and older | 94.8% | 1.10 |
|
5.
HCAHPS survey-recommend hospital
|
Age (excluding maternal measures) | 35 to 49 | 89.0% | 65 and older | 94.8% | 1.10 |
|
6.
HCAHPS survey-received information
|
Race and/or Ethnicity | White | 82.8% | Asian | 87.5% | 1.10 |
|
7.
HCAHPS survey-received information
|
Race and/or Ethnicity | Hispanic or Latino | 87.2% | Asian | 87.5% | 1.00 |
2. Equity Plan
USC Verdugo Hills Hospital (VHH) is an acute care facility with 140 beds serving Glendale, La Cañada Flintridge, and the Foothill communities for over 40 years. The hospital provides comprehensive clinical services across many specialties and has expanded key programs in orthopaedic surgery, gynecologic urology, and comprehensive breast care. VHH earned designation as a Primary Stroke Center and continued its designation as an Emergency Department Approved for Pediatrics. Patients benefit from access to cutting-edge treatments and access to renowned Keck Medicine of USC specialists, ensuring advanced, person-centered care. The hospital’s commitment to quality, safety, and clinical innovation are demonstrated through national recognition of honors such as the Emergency Department Lantern Award, Practice Transition Accreditation Program (PTAP) designation, an Echocardiography and Vascular Labs that is accredited by the Intersocietal Accreditation Commission, Leapfrog Safety Grade A distinction, the ICU Beacon Award for Excellence, and Center of Physical Therapy Excellence designation and its recognition as a “Great Community Hospital” by Becker’s Hospital Review.
Action Plan: VHH’s analysis of the HCAI Hospital Equity Report for calendar year 2024 highlights its commitment to equitable patient care, as the Top 10 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 communication and education opportunities, VHH is enhancing its multifaceted, hospital-wide approach to patient care and experience. 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 social drivers of health.
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, 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 evaluation, VHH 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, and where the organization can be confident that improvement initiatives are creating meaningful, measurable impact across all populations.
Measuring Success: VHH 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.
To ensure that improvement efforts achieve their intended outcomes without creating unintended consequences, VHH 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 variances, 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 CY 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 process interventions and outcomes, VHH 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 the 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.