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Quality Report

Summary of Quality Information
UCSF Medical Center
Org ID: 10095
505 Parnassus Avenue
San Francisco, CA  94143-0208
(415)353-2733
www.ucsfhealth.org

Accreditation
Programs 		Accreditation
Decision 		Effective
Date 		Last Full Survey Date Last On-Site Survey Date
Laboratory Accreditation Program
Accredited 10/22/2011 10/21/2011   10/21/2011  
Home Care
Accredited 4/14/2010 3/29/2013   3/29/2013  
Hospital
Accredited 4/17/2010 3/29/2013   5/10/2013  


Accreditation programs recognized by the Centers for Medicare and Medicaid Services (CMS)
Pathology and Clinical Laboratory
Home Health Agency
Hospital


Advanced Certification
Programs 		Certification
Decision 		Effective
Date 		Last Full
Review Date 		Last On-Site
Review Date
Primary Stroke Center
Certification 6/24/2011  6/23/2011  6/23/2011 
Ventricular Assist Device
Certification 10/16/2012  9/19/2012  9/19/2012 





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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number is not enough for comparison purposes.
4. The measure meets the Privacy Disclosure Threshold rule.
5. The organization scored above 90% but was below most other organizations.
6. The measure results are not statistically valid.
7. The measure results are based on a sample of patients.
8. The number of months with measure data is below the reporting requirement.
9. The measure results are temporarily suppressed pending resubmission of updated data.
10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Laboratory Accreditation Program
2011 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Home Care
2010 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Hospital
2011 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Oct  2011 -
Sep  2012
Children's Asthma Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pneumonia Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Surgical Care Improvement Project (SCIP)    
SCIP - Cardiac See Detail
   
SCIP - Infection Prevention
For All Reported Procedures:
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Blood Vessel Surgery
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Colon/Large Intestine Surgery
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Coronary Artery Bypass Graft
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Hip Joint Replacement
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Hysterectomy
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
  • Knee Replacement
 See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
  • Open Heart Surgery
 See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
SCIP – Venous Thromboembolism (VTE) See Detail
   
  Survey of Patients' Hospital Experiences (see details)
 
Hospitals voluntarily participate in the Survey of Patients' Hospital Experiences(HCAHPS).
Pediatric and psychiatric hospitals are not eligible to participate in the HCAHPS survey based on their patient population.
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
Ambulatory Surgery Center
400 Parnassus Avenue
San Francisco, CA  94143
      Beckman Vision Center
      545 Parnassus Avenue
      San Francisco, CA  94143-0644
        Services:
        • Outpatient Clinics (Outpatient)
        • Perform Invasive Procedure (Outpatient)
        Family Medicine Center at Lakeshore
        1569 Sloat Boulevard Suite 314
        San Francisco, CA  94143
          Services:
          • General Laboratory Tests
          • Outpatient Clinics (Outpatient)
          Hogan Eye Pathology Laboratory
          8 - 10 Kirkham Avenue
          San Francisco, CA  94143
            Services:
            • General Laboratory Tests
            OB/GYN Daly City
            333 Gellert Avenue
            Daly City, CA  94015
              Services:
              • General Laboratory Tests
              • Outpatient Clinics (Outpatient)
              Parnassus Heights Medical Center
              350 Parnassus Avenue
              San Francisco, CA  94143
                Services:
                • General Laboratory Tests
                • Outpatient Clinics (Outpatient)
                • Perform Invasive Procedure (Outpatient)
                Pediatric Outpatient Rehabilitation
                500 Parnassus Avenue
                San Francisco, CA  94143
                    Pediatric Specialties Practice at Santa Rosa, CA
                    100 Brookwood Avenue, Suite #100
                    Santa Rosa, CA  95407
                      Services:
                      • General Laboratory Tests
                      • Outpatient Clinics (Outpatient)
                      Positive Health Practice
                      350 Parnassus Avenue, Suite 908
                      San Francisco, CA  94143
                        Services:
                        • General Laboratory Tests
                        Surgical Movement Disorders Center
                        1635 Divisadero Street
                        San Francisco, CA  94143
                            UCSF Adult Chronic Dialysis
                            1675 Scott Street
                            San Francisco, CA  94115
                              Services:
                              • Administration of Blood Product (Outpatient)
                              • Dialysis (Outpatient)
                              • General Laboratory Tests
                              • Outpatient Clinics (Outpatient)
                              UCSF Ambulatory Care Clinic
                              400 Parnassus Avenue
                              San Francisco, CA  94143
                                Services:
                                • Administration of Blood Product (Outpatient)
                                • Administration of High Risk Medications (Outpatient)
                                • Dialysis (Outpatient)
                                • General Laboratory Tests
                                • Outpatient Clinics (Outpatient)
                                • Perform Invasive Procedure (Outpatient)
                                UCSF Cancer Center
                                2320 Sutter Street
                                San Francisco, CA  94143
                                    UCSF Cardiovascular Care & Prevention Center
                                    535 Mission Bay Blvd
                                    San Francisco, CA  94158
                                        UCSF Clinical Cancer Center
                                        1600 Divisadero Street
                                        San Francisco, CA  94115
                                          Services:
                                          • Administration of Blood Product (Outpatient)
                                          • Administration of High Risk Medications (Outpatient)
                                          • General Laboratory Tests
                                          • Outpatient Clinics (Outpatient)
                                          • Perform Invasive Procedure (Outpatient)
                                          UCSF Employee and Occupational Health
                                          2330 Post Street
                                          San Francisco, CA  94143
                                            Services:
                                            • General Laboratory Tests
                                            UCSF GYN (GYN-ONC & Genetics) Clinic
                                            100 Brookwood Avenue
                                            Santa Rosa, CA  95407
                                                UCSF Home Health Care
                                                3360 Geary Boulevard, Suite 201
                                                San Francisco, CA  94118
                                                  Services:
                                                  • General Laboratory Tests
                                                  • Home Health Aides
                                                  • Home Health, Non-Hospice Services
                                                  • Medical Social Services
                                                  • Occupational Therapy
                                                  • Physical Therapy
                                                  • Skilled Nursing Services
                                                  • Speech Language Pathology
                                                  UCSF Lakeside Senior Center
                                                  2501 Ocean Avenue First Floor
                                                  San Francisco, CA  94143
                                                    Services:
                                                    • General Laboratory Tests
                                                    • Outpatient Clinics (Outpatient)
                                                    UCSF Medical Center  *
                                                    505 Parnassus
                                                    San Francisco, CA  94143
                                                    Joint Commission Advanced Certification Programs:
                                                    • Primary Stroke Center
                                                    • Ventricular Assist Device
                                                      Services:
                                                      • Brachytherapy (Imaging/Diagnostic Services)
                                                      • Cardiac Catheterization Lab (Surgical Services)
                                                      • Cardiac Surgery (Surgical Services)
                                                      • Cardiothoracic Surgery (Surgical Services)
                                                      • Cardiovascular Unit (Inpatient)
                                                      • Coronary Care Unit (Inpatient)
                                                      • CT Scanner (Imaging/Diagnostic Services)
                                                      • Dialysis Unit (Inpatient)
                                                      • Ear/Nose/Throat Surgery (Surgical Services)
                                                      • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                                                      • Gastroenterology (Surgical Services)
                                                      • General Laboratory Tests
                                                      • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                                                      • Gynecological Surgery (Surgical Services)
                                                      • Gynecology (Inpatient)
                                                      • Hematology/Oncology Unit (Inpatient)
                                                      • Interventional Radiology (Imaging/Diagnostic Services)
                                                      • Labor & Delivery (Inpatient)
                                                      • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                                                      • Medical /Surgical Unit (Inpatient)
                                                      • Medical ICU (Intensive Care Unit)
                                                      • Neuro/Spine ICU (Intensive Care Unit)
                                                      • Neuro/Spine Unit (Inpatient)
                                                      • Neurosurgery (Surgical Services)
                                                      • Normal Newborn Nursery (Inpatient)
                                                      • Nuclear Medicine (Imaging/Diagnostic Services)
                                                      • Orthopedic Surgery (Surgical Services)
                                                      • Orthopedic/Spine Unit (Inpatient)
                                                      • Pediatric Unit (Inpatient)
                                                      • Plastic Surgery (Surgical Services)
                                                      • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
                                                      • Post Anesthesia Care Unit (PACU) (Inpatient)
                                                      • Radiation Oncology (Imaging/Diagnostic Services)
                                                      • Sleep Laboratory (Sleep Laboratory)
                                                      • Surgical ICU (Intensive Care Unit)
                                                      • Surgical Unit (Inpatient)
                                                      • Toxicology
                                                      • Transplant Surgery (Surgical Services)
                                                      • Ultrasound (Imaging/Diagnostic Services)
                                                      • Urology (Surgical Services)
                                                      • Vascular Surgery (Surgical Services)
                                                      UCSF Medical Center at 1500 Owens Street
                                                      1500 Owens Street
                                                      San Francisco, CA  94143-0208
                                                        Services:
                                                        • Administration of Blood Product (Outpatient)
                                                        • Administration of High Risk Medications (Outpatient)
                                                        • Anesthesia (Outpatient)
                                                        • General Laboratory Tests
                                                        • Outpatient Clinics (Outpatient)
                                                        • Perform Invasive Procedure (Outpatient)
                                                        UCSF Medical Center at Mount Zion
                                                        1600 Divisadero Street
                                                        San Francisco, CA  94115
                                                          Services:
                                                          • Brachytherapy (Imaging/Diagnostic Services)
                                                          • CT Scanner (Imaging/Diagnostic Services)
                                                          • Ear/Nose/Throat Surgery (Surgical Services)
                                                          • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                                                          • Gastroenterology (Surgical Services)
                                                          • General Laboratory Tests
                                                          • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                                                          • Gynecological Surgery (Surgical Services)
                                                          • Hematology/Oncology Unit (Inpatient)
                                                          • Interventional Radiology (Imaging/Diagnostic Services)
                                                          • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                                                          • Medical /Surgical Unit (Inpatient)
                                                          • Medical ICU (Intensive Care Unit)
                                                          • Nuclear Medicine (Imaging/Diagnostic Services)
                                                          • Orthopedic Surgery (Surgical Services)
                                                          • Plastic Surgery (Surgical Services)
                                                          • Post Anesthesia Care Unit (PACU) (Inpatient)
                                                          • Radiation Oncology (Imaging/Diagnostic Services)
                                                          • Surgical ICU (Intensive Care Unit)
                                                          • Surgical Unit (Inpatient)
                                                          • Ultrasound (Imaging/Diagnostic Services)
                                                          • Urology (Surgical Services)
                                                          UCSF Medical Center at Mount Zion - Medical Office Bldg 2
                                                          1701 Divisadero Street
                                                          San Francisco, CA  94115
                                                            Services:
                                                            • General Laboratory Tests
                                                            • Outpatient Clinics (Outpatient)
                                                            • Perform Invasive Procedure (Outpatient)
                                                            UCSF Medical Center at Mount Zion - Medical Office Building
                                                            2330 Post Street
                                                            San Francisco, CA  94115
                                                              Services:
                                                              • General Laboratory Tests
                                                              • Outpatient Clinics (Outpatient)
                                                              • Perform Invasive Procedure (Outpatient)
                                                              UCSF Medical Center at Mount Zion Women's Health
                                                              2356 Sutter Street
                                                              San Francisco, CA  94115
                                                                Services:
                                                                • Administration of High Risk Medications (Outpatient)
                                                                • Anesthesia (Outpatient)
                                                                • General Laboratory Tests
                                                                • Outpatient Clinics (Outpatient)
                                                                • Perform Invasive Procedure (Outpatient)
                                                                UCSF Mount Zion Hellman
                                                                2200 Post Street
                                                                San Francisco, CA  94143
                                                                  Services:
                                                                  • Outpatient Clinics (Outpatient)
                                                                  UCSF Mount Zion MOB Osher Center
                                                                  1545 Divisidero Street
                                                                  San Francisco, CA  94143
                                                                    Services:
                                                                    • General Laboratory Tests
                                                                    • Outpatient Clinics (Outpatient)
                                                                    UCSF Mount Zion Shumate Building
                                                                    2380 Sutter Street
                                                                    San Francisco, CA  94143
                                                                        UCSF Neurodiagnostics Outpatient Department
                                                                        2233 Post Street
                                                                        San Francisco, CA  94143
                                                                          Services:
                                                                          • Outpatient Clinics (Outpatient)
                                                                          UCSF Neuropathology BTRC Biomarkers Laboratory
                                                                          1450 3rd Street
                                                                          San Francisco, CA  94158
                                                                            Services:
                                                                            • General Laboratory Tests
                                                                            UCSF Pain Management Center
                                                                            2255 Post Street
                                                                            San Francisco, CA  94115
                                                                              Services:
                                                                              • Anesthesia (Outpatient)
                                                                              • Outpatient Clinics (Outpatient)
                                                                              • Perform Invasive Procedure (Outpatient)
                                                                              UCSF Pediatric Specialties - Marin
                                                                              1300 South Eliseo Dr. #204
                                                                              Greenbrae, CA  94904
                                                                                Services:
                                                                                • General Laboratory Tests
                                                                                • Outpatient Clinics (Outpatient)
                                                                                UCSF Primary Care Practice
                                                                                3490 California Street, Suite 200
                                                                                San Francisco, CA  94118
                                                                                  Services:
                                                                                  • General Laboratory Tests
                                                                                  UCSF Psoriasis and Skin Treatment Center
                                                                                  515 Spruce Street
                                                                                  San Francisco, CA  94143
                                                                                    Services:
                                                                                    • Outpatient Clinics (Outpatient)
                                                                                    UCSF Radiology Imaging Center
                                                                                    185 Berry Street
                                                                                    San Francisco, CA  94143-0628
                                                                                      Services:
                                                                                      • Anesthesia (Outpatient)
                                                                                      • General Laboratory Tests
                                                                                      • Outpatient Clinics (Outpatient)
                                                                                      • Perform Invasive Procedure (Outpatient)
                                                                                      UCSF Sleep Disorders Center
                                                                                      1800 Sutter Street
                                                                                      San Francisco, CA  94115
                                                                                        Services:
                                                                                        • Outpatient Clinics (Outpatient)

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