What is MAPS?

The MAPS Program conducts patient safety observations at the Ronald Reagan UCLA Medical Center and UCLA Santa Monica Hospital in accordance with the UCLA Hospital System Policies and Procedures Infection Control.

Click to view the UCLA Health System’s official policy regarding handwashing.


Project MAPS Overview

Project MAPS is an initiative by the Department of Patient Affairs, on request of Hospital and Nursing leadership at the UCLA Medical Center, and as a part of UCLA’s continuous effort to improve patient safety and the quality of care. MAPS has quantifiable audit tools that measure performance in clinical processes. Performance measurement represents what is done and how it is done. The goal is to accurately understand the basis for current performance so that better results can be achieved through focused improvement actions.


“To facilitate improvement of patient safety by observing clinical processes at UCLA Medical Center and provide highly reliable feedback to the leadership and management of UCLA healthcare.”

Safety & U.S. 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

The Joint Commission (TJC)

  • The Joint Commission on Accreditation of Healthcare Organizations
  • Independent, not for profit organization
  • Objectively evaluates and accredits nearly 20,000 healthcare organizations and programs across the U.S.
  • Surveys for Centers for Medicare and Medicaid Services (CMS)

UCLA & The Joint Commission (TJC)

  • 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.

Audit Tools

In order to measure performance, MAPS observers make use of two audit tools. The audit tools are paper based observation questionnaires that allow us to document clinical processes as per the guidelines suggested by JC. These audit tools adhere to JC’s patient safety goals for 2007. The audit tools are described below:

1. 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.

2. Personal Protective Equipment (PPE) – All PPE used by hospital personnel is  worn correctly when entering the patients room and properly disposed of when leaving.