***The MAPS Program conducts patient safety observations at the Ronald Reagan UCLA Medical Center according to the UCLA Hospital System Policies and Procedures Infection Control***
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.
In order to measure performance, MAPS observers make use of three main audit tools. The audit tools are paper based observation questionnaires that allow you to document clinical processes as per the guidelines suggested by JC. These audit tools adhere to JC’s patient safety goals for 2007. The three audit tools are described below:
1. Medication Administration – For correct identification of the patient for administering medication, JC guidelines suggest that before administering medication to patients, at least two patient identifiers (i.e. patient name and Medical Record Number (MRN) or name and date of birth) should be used. Labeling of syringes will also be measured.
2. Blood Specimen Draws – For correct identification of the patient for drawing blood, JC guidelines suggest that when drawing blood samples or giving blood products, at least two patient identifiers should be used before the procedure is carried out. These patient identifiers can be the patient’s name and Medical Record Number (MRN) or name and date of birth.
3. 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.
4. Personal Protective Equipment (PPE) – All PPE used by hospital personnel is worn correctly when entering the patients room and properly disposed of when leaving.