UCLA M.A.P.S. - Measuring to Achieve Patient Safety

Los Angeles
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Who are we?

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What is MAPS?
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


* 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.


* JCAHO conducted its audit of UCLA in April-May 2004
* UCLA received a perfect score from JCAHO
* One of the main objectives of Project MAPS (Measuring to Achieve Patient Safety) is to help the hospital get prepared for the JCAHO audit in the spring

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.”

Audit Tools
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 JCAHO. These audit tools adhere to JCAHO’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, JCAHO 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, JCAHO 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 - The policy, as described by JCAHO, is that caregivers are to wash their hands with soap and water for 15 seconds or use an alcohol-based cleanser between each patient contact. When applicable, all personal protective equipment (PPE) used by the personnel is disposed of when leaving the patient’s room.

Why should I join MAPS?
* Opportunity to shadow doctors, nurses, and the staff on the floors
* Access to many floors
o All the regular floors
o Intensive Care Units (ICU)
o Emergency Room (ER)
o Phlebotomy
o Pediatric
o and much more
* Interact with the nurses and the staff
* Explore various departments in the hospital
* Gain clinical experience
* Learn about various professions
* Learn about hospital administration
* Observe various medical procedures
* Very flexible hours (weekend shifts available)
* Meet peers with similar interests at our monthly meeting
* Your observations will be reported directly to charge nurses and unit directors
o Increase our patient’s safety

MAPS Volunteer Description

1. Conduct observations designed to improve patient safety.
2. Observe clinical practices in all inpatient care areas including Pediatrics, ICU’s and Emergency Room.
3. Produce quality data that will be used by Hospital administrators, clinicians, and staff members to further improve safety performance.

A day as a MAPS volunteer
Data Collection Process
On a regular basis, you will be required to follow the subsequent protocol:

1. Come to the Medical Center and sign in at the computer.
2. Make sure you are wearing your volunteer jacket and have your ID badge.
3. Check your schedule and the assigned area of observation.
4. Call the charge nurse/floor manager 10 minutes before you go to your designated area to let them know that you are coming.
5. When you go to your assigned area, introduce yourself to the charge nurse or floor manager.
6. Explain your purpose of observation.
7. Proceed with your observations with accuracy.
8. Communicate all of your observations to the charge nurse and unit director by giving them copies of your observation.
9. Fill out a tally sheet, and staple to original observations.
10. File observations in the folder marked with your name.
11. Sign out of the computer

For more information, visit our website at:

Visit the UCLA Medical Center's volunteer website at:

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