The Joint Commission
Quality Check
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
Home Care
Accredited 3/30/2013 3/29/2013   3/29/2013  
Hospital
Accredited 3/30/2013 3/29/2013   5/10/2013  
Laboratory Accreditation Program
Accredited 10/5/2013 10/4/2013   10/4/2013  


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 7/13/2013  7/12/2013  7/12/2013 
Ventricular Assist Device
Certification 10/16/2012  11/4/2014  11/4/2014 




Other Accredited Programs / Services
Hospital  -  Accredited by American College of Surgeons-Commission on Cancer (ACoS-COC)


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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.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Home Care
2013 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
2013 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:
Apr  2013 -
Mar  2014
Children's Asthma 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.
Emergency Department See Detail
Not displayed.
2
Not displayed.
2
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 above the target range/value.
This organization’s performance is above the target range/value.
Immunization See Detail
Not displayed.
8
Not displayed.
8
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.
Stroke Care See Detail
Not displayed.
8
Not displayed.
8
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 above the target range/value.
This organization’s performance is above 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 above the target range/value.
This organization’s performance is above 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
   
Venous Thromboembolism (VTE) See Detail
Not displayed.
8
Not displayed.
8
Laboratory Accreditation Program
2013 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 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
    Services:
    • Administration of Blood Product (Outpatient)
    • Administration of High Risk Medications (Outpatient)
    • Ambulatory Surgery Center (Outpatient)
    • Anesthesia (Outpatient)
    • Perform Invasive Procedure (Outpatient)
    Beckman Vision Center
    533 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)
        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
              Services:
              • Outpatient Clinics (Outpatient)
              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
                    Services:
                    • Outpatient Clinics (Outpatient)
                    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
                          Services:
                          • Outpatient Clinics (Outpatient)
                          UCSF Cardiovascular Care & Prevention Center
                          535 Mission Bay Blvd
                          San Francisco, CA  94158
                            Services:
                            • Outpatient Clinics (Outpatient)
                            UCSF Center for Geriatric Care
                            3575 Geary Blvd 1st Floor
                            San Francisco, CA  94143
                              Services:
                              • General Laboratory Tests
                              • Outpatient Clinics (Outpatient)
                              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
                                    Services:
                                    • Outpatient Clinics (Outpatient)
                                    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 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)
                                        • Inpatient 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)
                                        • Ophthalmology (Surgical Services)
                                        • Orthopedic Surgery (Surgical Services)
                                        • Orthopedic/Spine Unit (Inpatient)
                                        • Outpatient Clinics (Outpatient)
                                        • 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)
                                            • Inpatient 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)
                                            • Outpatient Clinics (Outpatient)
                                            • 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
                                                        Services:
                                                        • Outpatient Clinics (Outpatient)
                                                        • Perform Invasive Procedure (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
                                                                • Outpatient Clinics (Outpatient)
                                                                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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