
MAPS Overview
Objective
To facilitate improvement of patient safety by observing clinical processes at UCLA Medical Center and provide reliable feedback to the leadership and management of UCLA healthcare.
Audit Tools
In order to measure performance, MAPS observers make use of two audit tools.
- Hand washing– Described by TJC is that we follow current Center for Disease Control (CDC) or World Health Organization (WHO) guidelines. UCLA Health follows the CDC guidelines. The caregiver is to wash his/her hands for 15 seconds when soiled or if patient is on special contact precautions (example: spore) where this method is needed. The caregiver must also use alcohol-based cleaner between each patient contact.
- Personal Protective Equipment (PPE) – All PPE used by hospital personnel is worn correctly when entering the patients room and properly disposed of when leaving.
Safety and US Healthcare
- 98,000 deaths occur in the US each year due to errors in medical care
- 50% of these occurrences are preventable
- Healthcare industry is determined to improve and is imposing strict regulations towards patient safety
UCLA and the Joint Commission
- The Joint Commission (TJC) conducts a hospital wide audit every three years
- UCLA Ronald Reagan Hospital (RRH) had its last audit June 27 – July 1, 2016.
- UCLA RRH passed the three-year hospital survey with TJC excited about how well we run RRH with safety and quality for our patients.
- One of the main objectives of Project MAPS (Measuring to Achieve Patient Safety) is to help the hospital get prepared for the three-year Joint Commission Survey and any other Joint Commission Survey (Solid Organ, Ventricular Assistive Devise (VAD), Stroke, etc.).
- MAPS also helps the hospital be ready for any California Department of Health (CDPH) or CMS Survey.
- MAPS’ audit tools adhere to TJC’s National Patient Safety Goals (NPSGs). These goals are put on the National list since they are the most frequent occurring items that go wrong when a mistake in a hospital occurs.
For more information about who we are and what we do, see our info session powerpoint: