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Quality

Core Measures

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Core Measures

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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:

  • Stroke (STK)
  • Venous Thromboembolism (VTE)
  • Severe Sepsis/Septic Shock (SEP)
  • 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 and registries:

Heart Failure

Ronald Reagan UCLA Medical Center received the American Heart Association's Get With The Guidelines® Heart Failure Gold Plus Performance Achievement Award (2016. 2014, 2013, 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 2014, 2013 & 2012. 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

Target: Stroke, launched by the American Heart Association/American Stroke Association in 2010, is a national quality improvement initiative focused on improving acute ischemic stroke care by reducing door-to-needle times for eligible patients being treated with tPA. UCLA has consistently attained top honors in Target: Stroke recognition.

In 2015, Target: Stroke Honor Roll-Elite Plus was introduced. Target: Stroke Honor Roll-Elite Plus recognizes hospitals who achieve thrombolytic therapy times within 60 minutes of hospital arrival in 75 percent or more of acute ischemic stroke patients treated with IV tPA AND door-to-needle time within 45 minutes in 50 percent of acute ischemic stroke patients treated with IV tPA.

UCLA's Gold Plus award achievements

  • 2020 Gold Plus Target Stroke Elite Plus Honor Roll
  • 2019 Gold Plus Target Stroke Elite Plus Honor Roll
  • 2018 Gold Plus Target Stroke Elite Plus Honor Roll
  • 2017 Gold Plus Target Stroke Elite Plus Honor Roll
  • 2016 Gold Plus Target Stroke Elite Plus Honor Roll
  • 2015 Gold Plus Target Stroke Elite Plus Honor Roll
  • 2014 Gold Plus Target Stroke Honor Roll
  • 2013 Gold Plus Target Stroke Honor Roll
  • 2012 Gold Plus Target Stroke Honor Roll
  • 2011 Gold Plus Target Stroke Honor Roll
  • 2010 Gold Plus

UCLA Endovascular Recanalization for Acute Ischemic Stroke Outcomes - 2017

Outcome

Rate

Substantial Reperfusion (TICI 2b-3)

93%

Discharged to Home or Acute Rehabilitation

68%


NSQIP

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a quality improvement database that allows hospitals to focus their quality improvement efforts in the areas that matter most. Targeting high-risk and high complication rate procedures, NSQIP allows for better tracking, trending and high levels of data analysis. NSQIP participation also allows hospitals to collaborate on surgical care improvement while benchmarking like institutions.

The UCLA Health System Surgical Quality Team is very excited to begin participating in NSQIP. We will have more information about this great program posted soon.


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

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