Loma Linda University Health
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.
AHRQ PSI surgical death rate
|
Expected Payor | Medicare | 388.9% | Medicaid | 202.0% | 1.90 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 6.6% | Private | 3.5% | 1.90 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 6.6% | Private | 3.5% | 1.90 |
|
4.
HCAI 30-Day readmission NOBH
|
Expected Payor | Medicare | 5.9% | Private | 3.2% | 1.80 |
|
5.
HCAI 30-Day readmission MHD
|
Expected Payor | Medicaid | 9.1% | Private | 5.0% | 1.80 |
|
6.
AHRQ PSI surgical death rate
|
Expected Payor | Private | 362.1% | Medicaid | 202.0% | 1.80 |
|
7.
HCAI 30-Day readmission SUD
|
Age (excluding maternal measures) | 65 and older | 11.2% | 35 to 49 | 6.4% | 1.70 |
|
8.
HCAI 30-Day readmission SUD
|
Race and/or Ethnicity | Hispanic or Latino | 11.1% | White | 6.4% | 1.70 |
|
9.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | White | 83.6% | Hispanic or Latino | 48.7% | 1.70 |
|
10.
AHRQ PSI surgical death rate
|
Race and/or Ethnicity | White | 355.9% | Hispanic or Latino | 238.9% | 1.70 |
2. Equity Plan
Health Equity Action Plan: System-Level and Location-Specific Integration Executive Summary Loma Linda University Health (LLUH) is committed to advancing health equity by addressing disparities identified across the system and at each hospital location. This action plan outlines a unified, system-wide approach while preserving the integrity and specificity of each campus’s health equity initiatives. 1. System-Level Disparities and Overarching Strategies Key Disparities Identified (System-Level): - Cesarean Birth Rates: Significant variation by age and race/ethnicity (e.g., 4.7x higher in patients aged 40+ vs. 18–29). - Pneumonia Mortality Rates: Higher rates among older adults and certain payor groups (e.g., 3.2x higher for 65+ vs. 35–49; 3.1x higher for Medicare vs. Medicaid). - All-Cause Unplanned 30-Day Readmission Rates: Marked disparities by behavioral health diagnosis, payor, age, and race/ethnicity (up to 3.4x higher for some groups). Overarching System Strategies: - Standardized Data Analysis: All campuses will stratify outcome data by age, race/ethnicity, payor, and diagnosis, using dashboards and chart reviews to pinpoint disparities. - Root Cause Analysis (RCA): Interdisciplinary teams will conduct RCAs to identify workflow, communication, and care-transition gaps. - Targeted Interventions: Develop and pilot interventions tailored to high-risk groups (e.g., culturally tailored discharge protocols, enhanced follow-up for Medicare/Medicaid patients, age-appropriate care plans). - PDSA Cycles: Use Plan-Do-Study-Act cycles to test and refine interventions before scaling. - Monitoring & Accountability: Track progress using real-time dashboards, with regular reporting to the Health Equity Taskforce and leadership. - Leadership Oversight: Ensure executive sponsorship and cross-campus learning to scale successful interventions. 2. Maintaining the Integrity of Each Location’s Plan East Campus: - Focus: Age and payor-based disparities in readmission rates. - Approach: Prioritize deeper analysis of trends and interdisciplinary RCA; pilot interventions in units with the greatest variation; monitor outcomes by age, payor, and race/ethnicity. Medical Center: - Focus: Disparities by race/ethnicity (especially Black/African American vs. White) and payor (Medicare/Medicaid vs. Private). - Approach: Implement culturally tailored discharge protocols and enhanced care navigation for high-risk payors; conduct regular retrospective reviews; use the Health Care Equity Dashboard for real-time tracking. Murrieta: - Focus: Disparities in readmission rates by payor, age, race/ethnicity, and maternal outcomes. - Approach: Conduct data validation, RCA, and PDSA cycles; monitor trends using internal dashboards; coordinate improvement efforts with relevant workgroups. Surgical Hospital: - Focus: Patient experience and communication equity.’ - Approach: Conduct focused reviews and RCAs to ensure subtle disparities are identified and addressed; Pilot and refine communication and information-sharing interventions; Monitor HCAHPS trends quarterly to maintain equity across age, language, and sex groups. 3. Integration and Continuous Improvement - Cross-Campus Collaboration: Share best practices and lessons learned across campuses via the Health Equity Taskforce. - Customization: Allow each campus to adapt interventions based on local data and resource availability, while aligning with system-wide goals. - Continuous Feedback: Use outcome data to refine strategies, ensuring both system-level consistency and local relevance. 4. Next Steps - Finalize and disseminate this action plan to all campus leaders and stakeholders. - Schedule quarterly cross-campus Health Equity Taskforce meetings to review progress, share learnings, and adjust strategies. - Continue to engage frontline staff, patients, and community partners in the design and evaluation of interventions.
4. 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.