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Core Measures

About Core Measures

UCLA Health is committed to delivering the highest quality care according to nationally-recognized clinical care process improvement guidelines, including the Joint Commission’s core measures.  By complying with these processes, UCLA Health improves outcomes for patients treated in our facilities, and helps to reduce patients' risks for another adverse event requiring emergency care or hospitalization.  The following are a list of core measure sets that we track:

  • Acute Myocardial Infarction (AMI)
  • Heart Failure (HF)
  • Pneumonia (PN)
  • Surgical Care Improvement Project (SCIP)
  • Stroke (STK)
  • Emergency Department Throughput (ED)
  • Prevention: Immunization (IMM)
  • Pain Management (PM)
  • Chest Pain (CP)

Additional information on these measures can be found on the Joint Commission’s website.

Publicly Reported Information:

We report data publicly on all of the core measures above.  Results represent the average compliance percent for each process measure for patients diagnosed with the referenced conditions.  Hospital Compare offers information about the quality of care provided at UCLA Health.

Awards and Achievements:

Below are some of our most recent achievements related to core measures:

Heart Failure:

Ronald Reagan UCLA Medical Center received the American Heart Association's Get With The Guidelines® Heart Failure Gold Plus Performance Achievement Award (2012, 2011). The recognition signifies that UCLA has reached an aggressive goal of treating heart failure patients with 85 percent compliance for two years to core standard levels of care as outlined by the American Heart Association/American College of Cardiology secondary prevention guidelines for heart failure patients, which are reporting initiatives to measure quality of care.

The guidelines include aggressive use of risk-reduction therapies such as cholesterol-lowering drugs, beta-blockers, ACE inhibitors, aspirin, diuretics and anticoagulants in the hospital. Heart failure patients also receive alcohol/drug use and thyroid management counseling as well as referrals for cardiac rehabilitation before being discharged; all aimed to improve the quality of care provided to heart failure patients, save lives and ultimately, reduce healthcare costs by lowering the recurrence of heart attacks.

Acute Myocardial Infarction (AMI):

Ronald Reagan UCLA Medical Center has received the American College of Cardiology Foundation's NCDR ACTION Registry-GWTG Platinum Performance Achievement Award for 2012 - one of only 164 hospitals nationwide to do so. The quality-improvement program recognizes UCLA's commitment and success in implementing a higher standard of care for heart attack patients, and signifies that the hospital has reached an aggressive goal of treating these patients.

To receive the ACTION Registry-GWTG Platinum Performance Achievement Award, Ronald Reagan UCLA Medical Center consistently followed the treatment guidelines in ACTION Registry-GWTG for 8 consecutive quarters and met a performance standard of 90% for specific performance measures. Following these treatment guidelines empowers health care provider teams to consistently treat heart attack patients according to the most current, science-based guidelines and establishes a national standard for understanding and improving the quality, safety and outcomes of care provided for patients with coronary artery disease, specifically high-risk STEMI and NSTEMI patients.

Stroke:

UCLA Endovascular Recanalization for Acute Ischemic Stroke Outcomes - 2013
 

Outcome

Rate

Substantial Reperfusion (TICI 2b-3)

79%

Symptomatic Hemorrhage

8%

Discharged to Home or Acute Rehabilitation

45%


Get with the Guidelines (GWTG) Stroke Gold Plus Award (2012, 2011, 2010)

To receive the Gold Plus award, the UCLA Stroke Center achieved 85 percent or higher adherence to all GWTG–Stroke achievement indicators for two or more consecutive 12-month periods and demonstrated 75 percent or higher compliance with six of 10 GWTG–Stroke quality measures, which are reporting initiatives to measure the quality of care.  The award recognizes the UCLA Stroke Center’s implementation of excellent care for stroke patients, based on evidence-based guidelines.

GWTG Target Stroke Honor Roll Award (2011)

The award recognizes that over the most recent three-month review period, at least 50 percent of all eligible ischemic stroke patients at UCLA received the important clot-busting drug known as intravenous recombinant tissue plasminogen activator (tPA) within 60 minutes of arriving at the hospital. The drug is the only approved acute-stroke treatment for clot-related, or ischemic, stroke and has been shown to reduce stroke-related disability.

Resources:

Joint Commission’s award winning patient safety website, “Speak Up”

American Dietetic Association

Agency for Healthcare Research and Quality (AHRQ)

Heart Failure Society of America

National Institutes of Health (NIH)

California Department of Public Health

UCLA Health Wellness Initiative

American Heart Association